How many novel coronavirus (COVID-19) cases were announced today?

 is a volunteer effort to compile federal and state data in regards to new COVID-19 cases, including number of positive and negative tests.

Here’s the latest data, updated on July 1:

Articles

Data from the COVID tracking project on coronavirus cases, test results and more.

Coronavirus case numbers in the United States: JULY 1 update

In the inaugural episode of the "Off the Chart with Medical Economics" podcast, family physician Kurt Stange, MD, PhD, discusses how doctors can establish meaningful relationships with patients whom they treat only episodically or virtually. Stange, a former  editor of Annals of Family Medicine, is a Distinguished University Professor and professor of medicine at the Case Western Reserve University School of Medicine.

Podcasts

As long-term doctor-patient relationships dwindle, how can doctors establish the trust and respect they need in order to provide patients with the best care? 

How doctors can form relationships with patients they treat episodically or remotely

For doctors, choosing the right malpractice insurance and insurance carrier are crucial decisions. They need coverage that is affordable, tailored to their specific requirements, and provided by a financially sound company whose judgment they trust.

Slideshows

Here are answers to some basic questions and answers about malpractice insurance. 

The ABCs of malpractice insurance

How common is physician burnout and why does it happen?

Why do doctors experience burnout? 

Chris Mazzolini is the editorial director of Medical Economics

The recent surge in COVID-19 cases in many states across the South and Western U.S. has clinical laboratories concerned they are close to testing capacity.

The American Clinical Laboratory Association (ACLA), which represents major laboratories such as Quest Diagnostics, LabCorp and others, 

 that COVID-19 testing capacity will be exceeded in recent weeks.

“ACLA member laboratories have seen a steady increase in the volume of COVID-19 test orders," the statement reads. "While our members are collectively performing hundreds of thousands of tests each day, the anticipated demand for COVID-19 testing over the coming weeks will likely exceed members’ testing capacities. This significant increase in demand could extend turnaround times for test results."

, saying "we have continued to experience surging demand for these services, with recent daily orders outpacing capacity. As a result, while our average turnaround time continues to be one day for priority 1 patients, it is now three to five days for all other populations."

The company said its ramping up its capacity to conduct more than 150,000 tests per day. The company is currently doing about 115,000 tests per day, according to the statement. 

"While we have the supplies to meet our current capacity target, we continue to work with our industry partners on platforms, reagent test kits and other supplies," the statement reads.

More than 31.5 million coronavirus tests have been conducted in the United States since the pandemic began, with as many as 500,000 to 600,000 tests per day in recent weeks, according to the 

Labs say the recent surge in COVID-19 tests and cases has them closely approaching testing capacity.

COVID-19 tests: Labs warn they are approaching capacity as demand surges

Across the United States, healthcare resources at all levels are being directed toward fighting the 

 pandemic. While this has resulted in encouraging progress, many non-coronavirus patients are finding it difficult to access care due to limited available resources, while others avoid seeking in-person medical treatment for fear of exposure to the virus.

This trend is especially concerning among patients in need of chronic care, who account for 

. For those with chronic diseases, failure to access care can lead to high-acuity care episodes, a situation that is dangerous and disruptive to patients, in addition to being costly for patients, payors, and providers alike.

To avoid these negative outcomes, and to preserve specialist availability and critical health care resources, health care organizations must find ways to provide safe access to primary care for patients with chronic conditions. One potential avenue for providing this care is through the use of 

With eConsults, PCPs can provide virtual access to specialist-guided care, replacing the need for face-to-face specialist visits over 70% of the time, and triaging cases to ensure only the highest-acuity patients are referred for in-person appointments. This means patients with chronic conditions can continue to receive care in a safe environment, improving patient outcomes and mitigating a backlog of more urgent care that becomes necessary when untreated conditions worsen.

Coronavirus is further interfering with access to care

The novel coronavirus pandemic has exacerbated several already significant barriers to accessing care. 

, health officer and internist Dave Chokshi, MD, states that, “Even before COVID-19, we knew there were patients we do not see, whether because of financial barriers, racism, fear related to immigration status, or social isolation. [...] But now, that is compounded by additional barriers to seeking care, which span physical and technological challenges as well as concern about becoming infected with COVID-19.”

Regarding patients hesitant to seek care due to fear of exposure to the virus, the data are striking: from 

 we see a sharp and significant drop in the number of ambulatory visits. From April this number begins to rise, but remains roughly one-third lower than what was seen before the pandemic.

In addition, many other barriers to specialist care—such as financial, childcare, and transportation—have been heightened due to job losses, school closures, and stay-at-home orders. On the provider side, many specialists are not taking patients during the pandemic. Meanwhile, others are overbooked even more than usual due to their critical role in combating the pandemic.

Chronic care needs still must be addressed

While stay-at-home orders are important for reducing infections, patients with chronic illnesses must still be able to receive care to avoid severe negative outcomes. According to AristaMD user Maria Barrell, DO, 

, “Patients with a chronic illness who do not continually make key wellness checks could see their disease states deteriorate, launching into an acute care crisis.” Such crises can be costly, risky, and even fatal to those with chronic diseases, and providing care for such patients is critical to their wellbeing.

Such care is also important if health systems are to avoid being overwhelmed. In 2014 

 found 60% of US adults had at least one chronic condition. On average, Americans with five or more chronic conditions spend 14 times more on health services than people with no chronic conditions.

Increased acute health crises due to chronic patients not receiving care could therefore result in subsequent surges in ED visits as a downstream effect, with these admissions both taking over critical hospital and healthcare setting capacity amidst COVID-19, as well as contributing to a significant backlog of patients seeking care as the healthcare system is met with a second surge of patients following the height of COVID-19.

“I am worried about hidden illness due to foregone care, and how this might contribute to a ‘second wave’ related to this pandemic,” Chokshi says.

eConsults support chronic care management for PCPs

eConsults are a powerful tool that can support PCPs in providing patients with access to high-quality specialist care within the primary care setting. They can replace the need for a face-to-face visit 

 for routine referrals, and telehealth technology easily provides support for routine chronic care management such as check-ins and medication adjustments. Further, eConsults offer a method of remotely triaging to confirm which patients are high-acuity and therefore need to see specialists in person. For health organizations and medical centers already leveraging telemedicine to see patients, eConsults enable PCPs to provide necessary specialty care entirely through virtual means.

Implementing an eConsult system results in several short-term benefits amid the COVID-19 pandemic. PCPs can provide quick access to proactive care, resulting in improved patient health and higher overall satisfaction. This is especially true for those with chronic conditions; it’s been 

 that proactive care, especially primary care, is effective in reducing the burden of chronic conditions and improving outcomes for such patients.

As a further benefit, providing access to treatment and chronic care management through telehealth mitigates the need for patients to resort to emergency care in settings that are likely impacted with COVID-19 patients, helping reduce the risk of chronic patients being exposed to the virus.

Finally, eConsults can help to optimize specialist appointment queues, reducing wait times following the pandemic when specialists begin taking patients once more and experience a surge of patients with unmet needs.

Even amidst this healthcare crisis, patients with chronic diseases cannot be ignored. This population continues to need proactive, accessible care if their conditions are to be well-managed, and failure to do so will only exacerbate future healthcare strain. eConsults are a promising tool demonstrating the value of telehealth for remote chronic care management, equipping primary care providers to see patients virtually, provide specialty patient care remotely, and to do all of this in a timely manner.

The COVID-19 pandemic is testing healthcare organizations at all levels, prodding at weak points and forcing decision-makers to answer difficult questions about the interaction between providers and patients and how to best equip health systems to respond to crises. While the answers to many of these questions are not quite clear, what does seem certain is that very little will remain the same in healthcare in the coming years—and organizations willing to adapt and remain on the cutting edge will be the ones driving the industry forward as we overcome this healthcare crisis.

eConsults are especially vital during the COVID-19 pandemic.

eConsults: An essential piece of telehealth for chronic care management

Cardiovascular disease is one of the most common chronic conditions that primary care doctors treat, yet improving patient outcomes can be challenging for a variety of reasons. Treatment often requires a combination of prescription drugs and lifestyle changes, and patients need to adhere to all treatment recommendations to improve their health.

“There is the medical treatment side and the behaviors side, and the reality for many patients is that they struggle with both,” says Eugene Yang, M.D., FACC, University of Washington School of Medicine and chair-elect of the American College of Cardiology Prevention Section and Leadership Council. “It is across-the-board difficult to have a patient adhere to guidelines for their medications and also adhere to specific lifestyle recommendations that are based on clinical studies.”

As physician income becomes increasingly tied to patient outcomes through the CMS Quality Payment Program and value-based care contracts with private payers, these struggles can affect a practice’s bottom line.

“We are all increasingly being paid based on performance, and everyone is moving toward having a higher percentage of that type of payment model,” says Yang. “If you manage things well, you can reduce the rates of patients coming in with strokes and heart attacks.”

So what can physicians do to improve the cardiovascular health of their patient population? Experts say it starts with a firm understanding of each patient’s unique circumstances and adapting treatment plans to fit each individual patient.

One of the most common reasons a patient fails to follow a doctor’s treatment plan or fails to take prescribed medicine is social determinants of health. A patient who is urged to exercise may not have a street that is safe to walk on, limiting their options. The lack of a readily accessible grocery store can also present challenges for patients who need to eat a healthier diet. 

For some patients, the signs of a lack of food or safe housing may be obvious, but for others, physicians may not even realize social determinants are a factor.

“There are absolutely unseen barriers that, even for care teams with long-term cognitive patients, can go totally missed,” says Aaron George, D.O., FAAFP, director of medical education for Meritus Health in Hagerstown, Maryland. “Sometimes it’s obvious when you have a patient with challenges you have to work through, but there are often socio-economic, family and community barriers that the patients face that we lack the ability to see upfront.”

George says to be careful about placing patients into categories and to be aware that bias cuts both ways. A patient who has a low literacy level and is struggling with social determinants may have a tremendous desire to be healthy and be willing to do anything to achieve that goal. Conversely, a patient who appears affluent with a high education level and no financial issues may have little dedication toward living a healthier lifestyle.

“One approach to solving this is to have a standardized initial process for trying to understand where a patient is,” says George, noting that tools are available from many professional societies that help a physician identify how a patient lives and their barriers to care. “As a practice, implement one of those tools for every patient at the outset, perhaps at their first visit, before they even step in with the physician. You will start with a firm ... understanding where they are coming from, as opposed to having information trickle out over the course of months or years of care when their heart risk is increasing.”

Ada Stewart, M.D., FAAFP, president-elect of the American Academy of Family Physicians, says that understanding the patient’s specific challenges and building a solid relationship are key to keeping patients on track with their treatment plan — and that includes assessing their mental health. “Make sure you are looking at mental health issues, such as depression or other stressors like alcohol use, as those are really important to be able to find out why folks are not adherent to their regimens.”

Patients need goals to be successful but, according to experts, they also need to be part of the decision-making process when setting those goals. Patients need to understand their risks, what they can do to lower them and the importance of regular check-ins to chart progress or address challenges.

“Make patients accountable for their own health,” says Yang. “The way to do that is to increase the frequency of check-ins with patients. The more frequent check-ins, the better chance they feel they can achieve a certain goal.”

More frequent check-ins can also help identify what is working and what isn’t, says Yang. For example, a yearly checkup for cholesterol level won’t offer any insight into what the patient is doing that’s helping, but a more frequent one can help pinpoint behavior that is having an effect one way or another.

The pandemic’s boost to telemedicine may help doctors manage patients with cardiovascular disease better than before, says Yang. “With the increase in telemedicine, we are seeing more and more virtual visits, and that may allow us to increase the frequency of checking in,” he says. “The higher the frequency of checking in, the greater the benefits of achieving goals and maintaining adherence because the patient feels a stronger connection to the physician.”

When Stewart checks in with patients, she uses motivational interviewing techniques to see where they are in their treatment. For example, with high blood pressure, she’ll ask: “How is the medication working for you?” or “Are you able to take your medication every day?”

“If they say that they’re not taking their blood pressure medication, I try to make sure they understand the consequences of not taking it and emphasize the importance of the medicine, diet and exercise,” says Stewart. “Then I’ll address any barriers they have and let them know that I understand their challenges. You want to make sure that they recognize they are a partner in their health.” 

She says for some patients, focusing on one key goal may be the best strategy. “We fail a lot of times as physicians in making sure our regimens are simplified,” says Stewart. Maybe a patient won’t walk a mile a day, but maybe they are willing to walk down their street or to the mailbox and back. “We have to talk about what their goals are and what they see themselves doing to get there.” 

Experts say to be wary of overwhelming patients with too many goals and guidelines, or the patient may not achieve any of them.

“A lot of times you throw a whole bunch of things at them and you think they are listening, but when they come back for a follow-up, they didn’t do any of them because they didn’t understand,” says Stewart. “When they don’t hear you, we end up having increased hospitalizations and increased deaths, especially when we are talking about heart disease. If you put too much on them, then a lot of times they will just give up and say, ‘Forget it.’”

She says to set goals with the patient that they believe they can meet and keep making progress on, even if it’s in small increments. Other patients may be able to handle bigger steps. There’s no one-size-fits-all plan that works for everyone. “Every patient is not the same,” says Stewart. “You have to look at who your patient is, where they are, and what barriers they may have and what we can do to help them with those barriers.”

Yang says that some population health initiatives are helping to identify high-risk patients by assigning them risk scores based on hospital utilization. A team of caregivers is then assigned to help the patient better manage their blood pressure and keep track of how they are progressing toward their heart health goals. He adds that physicians should utilize nurses, advanced care providers and other staff as needed to help keep patients on track.

Stewart only has one care coordinator for her patient panel, and that person will reach out to patients that Stewart has identified as high risk for nonadherence. The care coordinator will follow up about two weeks after an appointment to make sure the person is taking their medication and isn’t experiencing side effects and to answer any questions.

But even without the benefit of a full care team or computer-generated risk scores, George says there is one warning sign of increased cardiovascular risk that often goes unnoticed by physicians.

“I think the biggest warning sign that we ignore nationally is the subtle creep of weight gain,” says George. “I rarely find a patient that puts on 60 pounds in six months; it’s three pounds one year, four pounds the next year and six pounds the next year. Somehow, I think we all tolerate it and accept it as an almost unfortunate norm.”

Because the weight gain is minimal, physicians tend to ignore it and the patient is willing to accept it, says George. “I’m really quick to show patients the trend of their weight gain over the last eight years or 10 years, and how it’s gone up just a couple of pounds each year. I tell them, ‘Imagine where you’re going to be 10 years from now or five years from now.’”

Paying attention to patient trends is an important part of monitoring cardiovascular health, and the more patient contact, the better.

“I can tell you that without a doubt, almost all my patients in the days leading up to their visit will take their medications because they want their blood pressure to look good, or they won’t eat bad foods for a couple days before they are having their lipid tests done,” says George. “But we don’t live life like that. For the majority of patients, the more frequent touch points that are brief and done by nonphysician team members are going to be increasingly important.”

With the right strategy, physicians can help patients stay on track for improved outcomes.

Personalize care to improve patient heart health 

While medical practices are understandably focused on financial survival, keeping up employee morale amid the fear and uncertainty surrounding COVID-19 is equally important, practice leaders say. And the keys to that are ensuring that employees feel safe and valued, and above all, building trust through regular communication.

“We’ve been communicating, communicating, communicating (since the start of the pandemic),” says Susan Coker, practice administrator of Tri County Internal Medicine in suburban Atlanta. That communication takes the form of daily huddles that she conducts with front-office staff and that the medical director conducts with the practitioners. They use the huddles to discuss everything from upcoming reductions in hours to the latest guidance from the Centers for Disease Control and Prevention.

Coker says employees use the daily huddles to ask questions, voice concerns and offer suggestions. “We always start by asking how everyone’s doing, and they’re good at communicating back to me,” she says.

At the Center for Primary Care-McDuffie Medical, part of an eight-practice independent practice consortium near Augusta, Georgia, physicians met daily with the practice administrator and key staff members during the first weeks of the crisis to assess how things were going and address problems and employee concerns, says Jacqueline W. Fincher, M.D., MACP, one of the practice’s five physicians. 

Following those meetings, their administrator would participate in conference calls with the practice’s other seven administrators to share information and coping strategies. “Communication is so important for making people feel valued, giving people a sense of, ‘We’re going to get through this together, and we’re going to do it safely,” says Fincher. 

In addition, the practice has been letting employees take off Friday afternoons or Monday mornings. “It extends the weekend a little and provides an additional break from the intensity of the job,” she says. 

Owen Dahl, MBA, CHBC, a medical practice management consultant and principal of Owen Dahl Consulting in Texas, suggests practices sponsor employee games and offer perks such as gift cards and catered lunches as morale boosters. Bringing in lunch has the added benefit of keeping employees in the office, thereby reducing their chance of becoming infected with COVID-19. 

Dahl also recommends looking for ways to provide staff members a sense of engagement with the practice beyond their own job, such as participating in task forces to create policies for working from home and other changes the pandemic is likely to bring about.

“The more you can get your staff involved and committed to the culture change that’s going to come,” he says, “the better off you’re going to be.”

While medical practices are understandably focused on financial survival, keeping up employee morale amid the fear and uncertainty surrounding COVID-19 is equally important.

Maintaining employee morale during COVID-19

The U.S. Justice Department (DOJ) has charged 10 people from across the country for their part in an alleged rural hospital pass-through billing scheme.

, the defendants, which include hospital managers, lab owners, billers, and recruiters, are accused of using rural hospitals in several states as billing shells to submit fraudulent claims to insurance companies for $1.4 billion in laboratory testing from November 2015 through February 2018. The defendants allegedly collected approximately $400 million in the scheme.

The defendants hail from Florida, Illinois and Georgia, and all but one of them were charged with one count of conspiracy to commit healthcare fraud and wire fraud. Meanwhile four were charged with five counts of substantive healthcare fraud each, two were charged with two counts of conspiracy to commit money laundering, six were charged with one count of conspiracy to commit money laundering, and eight were charged with multiple counts of substantive money laundering, according to the release.

The hospitals involved in the case are: Cambellton-Graceville Hospital, a 25-bed rural hospital located in Graceville, Fla.; Regional General Hospital of Williston, a 40-bed facility located in Williston, Fla.; Chestatee Regional Hospital, a 49-bed rural hospital located in Dahlonega, Ga.; and Putnam County Memorial Hospital, a 25-bed rural hospital located in Unionville, Mo., the release says.

The release says that the defendants would allegedly take over small, rural hospitals, usually in financial trouble, through managing companies which they owned and operated then bill private insurers through the hospitals for millions of dollars of expensive urinalysis drug tests and blood tests conducted mostly at outside laboratories often controlled by or affiliated with the defendants through billing companies the defendants also controlled by the defendants. Despite most of the tests being performed by outside laboratories, the defendants claimed the tests were performed in-house, the release says.

Through these hospitals’ negotiated contracts with private insurers, lab tests performed in-house received a higher reimbursement than those performed in an outside laboratory, so the hospitals were allegedly used as shells to fraudulently bill for the tests, which often were not medically necessary, the release says.

The defendants allegedly obtained urine and other samples for testing through kickbacks paid to recruiters and healthcare providers at sober homes and substance abuse treatment centers. Additionally, the defendants are accused of engaging in sophisticated money laundering to promote their scheme and distribute the profits, according to the release.

“Trust and integrity undergird the confidence and reliability in our healthcare system,” U.S. Attorney for the Middle District of Florida Maria Chapa Lopez, says in the release. “Fraudulent and deceptive business practices undermine those values and erode the public’s trust in that system. We will continue to pursue those who set these tenets aside and compromise the care and safety of our citizens for profit.”

The defendants include hospital managers, lab owners, billers, and recruiters.

Feds charge 10 in $1.4 billion rural hospital billing scheme

On March 3, Susan Coker, the practice administrator of Tri County Internal Medicine in suburban Atlanta, and Kelly Stopek, the practice’s medical director, left for a vacation in Costa Rica. When they returned a week later, Coker recalls, “the world had changed.” COVID-19 had arrived.

“Since March 10, we’ve spent 90% of our time on COVID-19 in some form,” Coker says, adding that the practice began seeing a “dramatic decrease” in patient visits following President Donald Trump’s national emergency declaration a few days later. Through the end of April, patient visits were 50% to 60% of what they’d been pre-pandemic, and the practice’s revenues were poised to take a similar hit. “If your charges aren’t coming in, then the payments won’t be there either,” she says. 

In anticipation of diminished income, Tri County eliminated its evening hours of operation, cut everyone’s pay by half and furloughed some staff members. But thanks to a $400,000 loan obtained under the Paycheck Protection Program (PPP) and the beginnings of a rebound in patient visits, the practice has started bringing back furloughed employees and restoring salaries, Coker says. 

Tri County, of course, is hardly alone in feeling the impact of COVID-19. In a Medical Group Management Association (MGMA) member survey conducted the first week of April, practices reported an average decrease of 55% in revenue and 60% in patient volume since the onset of the pandemic. And data from the U.S. Department of Commerce’s Bureau of Economic Analysis show spending on health care overall fell by 18% in the first quarter of 2020 — before the full effects of the coronavirus had even become apparent. 

Meanwhile, a joint survey by the Primary Care Collaborative and the Larry A. Green Center found that as of early May, 42% of respondents had laid off or furloughed employees, and 13% predicted they would close within the next month.

Making the picture bleaker — especially for primary care practices — has been the accompanying drop in ancillary services. In an MGMA survey in late May, about half of respondents said their ancillary service volume had declined by 51% or more since the onset of the pandemic. Another 40% reported declines of between 11% and 50%.

“A primary care practice can’t make it financially just on submitting E/M codes,” says Jacqueline W. Fincher, M.D., MACP, president of the American College of Physicians and one of five doctors at McDuffie Medical in Thomson, Georgia. “It’s the ancillaries like EKGs, lab work and breathing tests that really support your office. And right now, primary care practices are losing that business.” 

Fincher says overall revenue for the Center for Primary Care, the regional independent practice consortium to which McDuffie Medical belongs, was down 20% in April 2020 compared to April 2019, and the expected falloff for May was 25% to 30%.

Faced with these unprecedented circumstances, as well as uncertainty about the future, what can primary care providers do to stay afloat financially and continue caring for patients? The answer, according to practice management experts, lies in doing what practices have always done during times of crisis: Look for ways to increase revenue and hold down expenses, while communicating frequently with patients and staff.

On the income side of the equation, “telemedicine is your best bet,” practice consultant Elizabeth W. Woodcock, MBA, FACMPE, told attendees of the recent “COVID-19 Practice Survival Guide” webinar hosted by Medical Economics®. Woodcock added that several of her clients were aiming to get patient visits back to 75% of their pre-pandemic levels by the beginning of June through a combination of telemedicine and in-office visits.

Increasing numbers of practices are adopting that strategy. According to data compiled by The Commonwealth Fund in early May, 12% of visits to ambulatory care practices were conducted via telehealth. That compares to fewer than 1% of visits two months earlier. 

CMS, too, is encouraging greater use of telehealth during the pandemic by increasing Medicare payments for some telehealth visits to match those of in-office visits, retroactive to March 1. It is also loosening restrictions on how and where telehealth services may be provided and who can provide them. For example, patients now can have telehealth visits from home rather than having to travel to a designated originating site, as they were previously required to do. And doctors now are allowed to provide telehealth visits with patients in other states. 

Woodcock advises practitioners who haven’t previously used telehealth to rehearse visits before trying them with patients. “Role-playing helps you figure out how to deal with the paperwork and side issues, like consent, scheduling and virtual rooming,” Woodcock explains.

Ideally, she says, rehearsals should include a physician, a scheduler, someone to role-play a patient and a medical assistant. The latter’s responsibilities should include getting the patient on the phone, ensuring the technology is working correctly and performing clinical intake before turning the patient over to the doctor. When the visit is finished, the scheduler can set up any needed follow-up appointments.

Stopek says Tri County began providing telehealth visits within a few days of the mid-March national emergency declaration. “We just kind of threw it out there and fixed any problems as they came up, until it was a smooth workflow,” she recalls. By early May about 20% of the practice’s visits were being conducted that way.

Patients generally seem happy with telehealth treatment, Stopek adds. “They’re getting a lot of their problems addressed with the comfort of not having to come here, where they’re worried they might get infected.” 

Still, she says, from a health care standpoint, telehealth is a double-edged sword. “You want to be sure you’re taking care of the patient the best you can, but sometimes there’s a limit to how much you can do with a phone visit.”

Fincher agrees. “Sometimes the risk (of an office visit) is less than them having a heart attack at home,” she says. “If I think they’re having an exacerbation of congestive heart failure, I’ve got to know if they have swelling in their legs and what their lungs sound like. I can’t do that over the phone.”

Like Tri County, the Center for Primary Care began offering telehealth visits immediately after the emergency declaration, and by late April they accounted for about 60% of its visits, says Fincher.

The biggest challenges Fincher and her colleagues face with telehealth visits have been demographic and technological. “We’re in a rural area with a lot of older patients,” she explains. “Many of them don’t have smartphones or are in places where bandwidth is limited,” and thus can’t access the practice’s patient portal.

“Just to get a patient connected can take as long as the appointment, especially the first time, because it’s all new for them,” she says.

 Bent Tree Family Physicians, a seven-physician family practice with locations in the Dallas area, encountered a somewhat different challenge when it began offering telehealth visits: patient anger.

“Our patients weren’t used to telehealth, and for a lot of them the reaction was, ‘Wait, you’re going to bill me for this?’ because they had been accustomed to getting a lot of that phone care for free,” says Guy Culpepper, M.D., Bent Tree’s founder and now one of three owners. 

But from a revenue standpoint, the practice had little choice, Culpepper says. In-person visits had fallen from a daily average of 200 pre-COVID to between 10 and 20 in early May. Moreover, revenues from sonograms, stress tests and other ancillary services had all but disappeared. In April, the practice applied for but didn’t get a PPP small-business loan, leading it to furlough most of its 70 employees and the partners to forego their own pay. 

However, help came soon after from a different, albeit unexpected, source: Bent Tree’s patients raised $750,000 through a GoFundMe page, which enabled the practice to bring back some staffers. (The practice was able to obtain a PPP loan in May, which allowed it to rehire the rest of those it had furloughed.)

When it comes to reviving ancillary services, there’s nothing new or unusual for practices to try, says Owen Dahl, MBA, CHBC, a medical practice management consultant and principal of Owen Dahl Consulting in Texas, who participated in the recent survival guide webinar by Medical Economics®. Patients have to be persuaded to return, and the keys to that are communication and reassurance — and patience. 

“Let patients know what you’re doing to keep them safe,” he says. “Show them with videos on your website or testimonials from other patients that you have everything under control and they’re not jeopardizing their safety by coming in.” All forms of communication, including phone calls, texts, emails and frequent updates on the practice’s website, are useful in maintaining relationships with patients, Dahl adds.

In addition to exploring ways to maintain revenue during the pandemic, experts say that practices need to scrutinize overhead costs and reduce or eliminate any that aren’t essential to practice efficiency or patient care. And since salaries and benefits usually account for the largest share of overhead, reducing those costs often requires furloughs and/or layoffs.

Although layoffs are always painful, Dahl says the process can benefit a practice in the long run if conducted strategically. He recommends assessing each employee’s skills and how — or whether — those skills fit with the practice’s long-range goals and can be adapted to the different ways care will be delivered post-pandemic.

“We know that telemedicine is going to be a big part of the equation in the future,” he says. “So what are the core competencies and skill sets practices are going to need from their employees to succeed in that environment?”

In addition, with fewer employees, those who remain can be cross-trained to enable them to take on additional tasks, thereby increasing their productivity and value to the practice. 

In the end, though, every practice is hamstrung in its forecasting by the unpredictable nature of COVID-19 and its impact on health care. “It’s an incredibly confusing time (for) everything, from knowing what’s the right thing to do for patients to how to handle your staff,” Dahl says. “All we can really do is take it one day at a time.”  

Faced with unprecedented circumstances due to COVID, as well as uncertainty about the future, what can primary care providers do to stay afloat financially and continue caring for patients?

Meeting the financial challenges of COVID-19 

The American College of Physicians (ACP) has released a position paper aimed at ensuring that electronic communication between patients and physicians are thoughtful and effective while also maintaining standards of ethics and professionalism.

American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations

and was developed by the ACP Ethics, Professionalism and Human Rights Committee (EPHRC). It makes recommendations for physicians navigating these new forms of communication with an emphasis on ethics and professionalism, privacy and confidentiality, and price considerations.

While the paper looks at using email, patient portals, texting , and messaging applications used by patients and physicians, but does not examine telemedicine, telephone, video, or other applications; or communication between clinicians, the release says.

The recommendations for electronic communication in the position paper include:

They should not take the place of in-person communications

They should only take place after discussion with the patient about expectations and appropriate uses, and with the patient’s consent

It should occur through a method that is patient-centered and secure such as a patient-portal

These communications should be documented in the medical record

If these communications are done with attention to ethical and other concerns, they can help improve patient care, satisfaction, and clinical outcomes

Electronic communications should be used by physicians and institutions to promote health equity and proactively address the socioeconomic and demographic factors that can lead to disparities in uptake and utilization

Physicians, patients, and institutions should recognize and address increased workload associated with electronic communication and the impact that can have on physician well-being

“This paper is particularly timely given the COVID-19 pandemic,” Jacqueline W. Fincher, MD, MACP, president of ACP, says in the release. “E-communications have become necessary and powerful tools that have the potential to help improve quality, patient satisfaction and access to health information and clinicians but they must be used with care and with clear and mutual understanding of patients and clinicians.”

 says that physicians must act in the best interest of the patients and should take care to extend standards for maintaining professional relationships and confidentiality.

The new position paper lays out how electronic communication can be used thoughtfully and effectively.

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