Editor's note: This is one of three articles aimed at helping small practices survive the COVID-19 crisis. The other two articles address:

The outbreak of the Covid-19 virus is having a financial impact on private practices nationwide. Experts say that many practices are seeing a decline in patient volume as people try to avoid doctors’ offices unless they have no other choice, and that decline is expected to continue as the crisis broadens.
	
	“This is especially true for primary care offices,” says Lisa Stevens Anderson, president of Equality Health’s Management Services Organization division, who oversees 1,200 primary care physicians. “They are the lowest paid on the physician spectrum and have the busiest offices. They are the ones during the initial phase that are the hardest hit as they try to adjust to the new normal and how to maneuver in this business environment.”
	
	Right now, there are so many unknowns that keeping a practice profitable is a daunting challenge. If the crisis lasts for months, as many expect, it could threaten the viability of practices that were already struggling as patient volume continues to decline. Experts say practice leaders need to accept that their practice is most likely going to take a financial hit and start planning accordingly.
	
	“This could have a major impact on each practice,” says Owen Dahl, MBA, FACHE, a medical practice management consultant. “Throw in an employee who gets the virus or has to stay home because of their kids, and it could become a major issue.”
	
	


	
	Dahl says to start running projections on what the practice finances would look like if revenue dropped 10, 20, 50 or even 80 percent. “Building pro formas on what the impact would be is critical,” says Dahl. “Start there, then look at what patients you need to see and what you can do to generate revenue in some fashion.” With the loosening of telehealth restrictions, some practices may be able to keep patient volume up while still getting reimbursed by Medicare and commercial payers.
	
	“You have to really over-plan at this point,” says Joseph Valenti, MD, board member of The Physicians Foundation. “We could really be looking at many months of problems, and a lot of practices may not survive that. We can’t get into a situation as a nation where physicians are unable to keep the doors open financially and are unable to take care of patients when they most need them.”
	
	Expenses need a careful review after the projections are complete. “You may have to lay off employees or rotate staff to work alternating days,” says Dahl. “You don’t want to lose staff if you can help it, because you will need them to recover.”
	
	If a practice doesn’t have a line of credit, Dahl says, now is a good time to apply for one. The money could be the difference between practice survival or going out of business. “It’s for these kind of emergency situations,” says Dahl. The proforma projections will help determine where the money needs to be spent.
	
	Valenti says an SBA loan is another option if a line of credit isn’t available, and that doctors should not be reluctant to reach out to vendors to renegotiate or ask for more repayment time. Because some vendors won’t send more products if payments are in arrears, Valenti says it’s important to reach out and explain the situation to see if they will grant an exception.
	
	“The same thing goes with rent-you may need to ask for a lease abatement,” he adds. “You have to make your practice as trim and fit as possible. All you can do is ask, and the worst thing they can say is no.”
	
	Don’t forget professional associations, says Anderson, who notes that many are providing resources and guidance to their members during the emergency. For example, the American Academy of Family Physicians (AAFP) recently called on Congress to establish a 24-month, interest-free loan program for small and independent practices that have been negatively impacted by the COVID-19 crisis. The AAFP has also called for provisions that would require Medicaid to reimburse at Medicare rates and has also asked for a grant fund so that small practices could purchase telehealth equipment.
	
	Doctors should also look at a worst-case scenario. If the practice had to close because too many employees are sick, or all the doctors are sick, it could trigger business interruption insurance coverage. So Dahl says to make sure to understand what is and isn’t covered and prepare accordingly.
	
	


	
	Boosting staff morale is also key to maintaining focus on patient care and to getting everyone to work toward keeping the practice open.
	“I think it’s important, so say to the staff: ‘Let’s get through today and not think about the future, but two to four weeks from now, let’s start to think about what the future holds,” says Dahl. “What does it hold, how can we make sure we improve care and come out of this whole?”
	
	“Recognize the stress the staff is under,” says Anderson. “Make regular, timely communications about efforts to maintain the office, take care of patients, and maintain financial viability. If employees don’t have information, they get scared.”
	
	If staff cuts are being considered, Anderson says to explain the situation to the staff and see if they have any ideas. Instead of assuming no one wants their hours reduced, for example, someone may volunteer because of their current life circumstances. “If you can stay connected during this time you can increase and reinforce their loyalty,” she says.
	
	Valenti says that the crisis might help reaffirm the important role of physicians in the healthcare system. “With the relaxation of some of the CMS rules, I think we are about to demonstrate why over-regulation is not a good thing,” he says. “We all need some regulation, but when it’s overdone, it hinders our ability to practice and we become less efficient. I think deregulating some of these things during the pandemic will prove we don’t really need them.”

Articles

Practice leaders need to accept that their practice is most likely going to take a financial hit and start planning accordingly.

Coronavirus practice guide, part 1: Financial steps to save your practice during the coronavirus outbreak

If the Coronavirus pandemic contains any silver lining for primary care doctors, it may be to speed the adoption of telemedicine and other alternatives to in-person patient visits.

While technology enabling doctors to provide some forms of care remotely has been available for decades, adoptions has been slow due to privacy concerns, lack of adequate reimbursement, technology costs and physician inertia. But with patient visits dwindling as a result of the coronavirus pandemic, clinicians have been turning to e-mail, texting, and telemedicine to maintain contact with and provide care for patients. And that could be a positive development to emerge from the current crisis, says Ron Holder, MHA, FACMPE, chief operating officer of the Medical Group Management Association.

“This may be just the impetus needed to prepare for what’s going to be the future of healthcare anyway, Coronavirus crisis or not,” Holder says. And with fewer patients coming in, he adds, “this is your opportunity to try some of the things you may have been wanting to try but hadn’t had the time.”

The federal government is providing additional encouragement to use telemedicine, in the form of increased Medicare reimbursements and a loosening of HIPAA’s privacy, security and breach notification rules.


	So how should a practice get started with telemedicine? The first step, experts say, is to find a platform-the technology that enables secure, HIPAA-compliant video and audio communication with patients via computer, smartphone or other electronic device.

Platforms typically will provide a method for registering patients, a virtual queue/“waiting room” for patients, and a method of recording and archiving the encounter, explains Russell Libby, MD, a board member of The Physicians Foundation and president of the Virginia Pediatric Group, which has been offering telemedicine visits for a little over a year. 

A Google search can yield a great deal of useful information on telehealth platforms and services, Libby says. In addition, The Physicians Foundation has joined forces with the AMA and several state medical societies to form the Telehealth Initiative, a repository of telemedicine-related advice and resources for practices and individual physicians.

Ideally, a telehealth platform will integrate with the practice’s website, so that the process of connecting with a provider is seamless to patients, says Eric Haden, founder and president of the telehealth consulting firm Drexly Health Solutions LLC. “You want to list your providers on the home page and have the patient be able to click on a provider’s name and be entered into the [virtual] waiting room,” Haden explains. 


	Haden advises practices offering telehealth for the first time to focus on simplicity and flexibility. That means using a standalone platform, one that’s not necessarily part of a fully integrated EHR system but whose only function is enabling remote communication with patients.

“The important thing is just to get some clinicians using it now, so you can continue seeing patients,” he says. “Start small and get used to it, then grow and fit it into your practice. I tell my clients, ‘Instead of buying the whole cow now, you just need the milk.’”

At the same time, it’s important that the platform have expansion capabilities so that the practice can add users and functionality in the future. “Some of the products out there only offer solutions for use by individual doctors,” he says. “It’s better to pick an individual solution from a vendor that offers practice-wide capabilities so you can easily integrate with them in the future if you decide to.”

One important caveat for practices using standalone platforms, Haden adds, is that they will need a way to download recordings of patient visits into their EHR so they can be added to the patient’s record.

Given the fluidity of the current situation, Haden also advises against signing a long-term agreement with a vendor, but instead look for one that permits month-to-month contracts and/or offers free trials. “Before investing in any telehealth service, investigate your options,” he says. He also cautions that, with the increased demand for telehealth services, practices can expect waits of a week or more to get set up with a platform. “Normally, it gets done in one to three days,” he says. 

Some practices, Haden notes, have a telehealth platform in their current EHR system that they aren’t using. If so, he says, now is the time to try it out-unless the vendor charges exorbitant fees or requires a long-term contract for setting it up and using it. 


	Extensive use of telemedicine services most likely will be accompanied by changes in a practice’s workflow and staff responsibilities, and possibly require some physical alterations. “People are going to have to assume different roles depending on each practice’s circumstances,” says MGMA’s Holder. He cites the example of a nurse who, finding she’s spending less time performing hands-on patient care, instead triages requests coming through the practice’s patient portal and deciding which provider they should be routed to.

In addition, Holder says, practices will need to ensure that every clinician has access to space where they can conduct telehealth visits in private, so as to comply with HIPAA privacy rules.

Once a practice has acquired telemedicine capabilities, the next step is informing patients. The most effective ways to do this, says Holder, is via e-mail and/or the practice’s website. Both methods should explain the service, contain instructions for how to register for it, and include a link for accessing the virtual waiting room.

In addition to telehealth, doctors can use e-mails and text messages for remote communication. In order to be HIPAA-compliant, however, e-mail correspondence must take place through a patient portal, while text messages require the use of a secure server that encrypts the messages. Some telehealth vendors will include these technologies in their platforms for an additional fee, Haden says.

Experts predict that practices adopting telehealth in response to the coronavirus pandemic will soon come to see its advantages, starting with happier patients. “My clients have found that once their patients experience telehealth their satisfaction levels are through the roof, and they never want to go back to the old way of receiving care,” says Haden.

Libby notes that introducing telehealth is an opportunity for reducing care costs while improving outcomes. By making it easier for practices to check on and monitor patients with chronic conditions, telehealth can reduce emergency department visits-an outcome especially important to a practice in an ACO or paid under some form of universal capitation.

“This is opening the box, and doctors are seeing it’s a comfortable box to be in,” Libby says. “They can use it to benefit their patients, their practice, and their community.”

Coronavirus practice guide, part 2: Crisis could boost telemedicine use

Editor's note: This is one of three articles aimed at helping small practices survive the COVID-19 crisis. The other articles address:

As the COVID-19 coronavirus sweeps the globe and uncertainty increases, physicians and practice leaders should turn their attention to the welfare of their staffs and their patients.

Gary Price, MD, a Connecticut plastic surgeon and president of The Physicians Foundation, says that in times of crisis such as this, it is important to start by re-examining the practice’s fundamental mission.

“We're here to keep people healthy and happy in the end,” Price says. “So that's an important thing to keep in mind as we make the rest of the decisions.”

Price advises getting as much information as possible about the situation, so that physicians and practice managers can ask the proper questions, such as whether it is necessary to have patients who are not in dire need of care come into the office or facility.

Once information is gathered, experts say that communication with staff is crucial, not only so they know what is required of them but also to calm any fears they may have.

Jagdesh Khubchandani, Ph.D., a Ball State health science professor, says practice leaders should remember that their staff is made up of human beings under a remarkable amount of stress and should adjust their interactions in the interest of maintaining staff morale.

“For physician leaders and practice leaders, they have to first know that everyone around them is scared, they go home, and they deal with the fear of their family, or the risk of infecting other family members,” he says. “So, I think as a leader in practice, physicians should hopefully be kind in their communication, watch their own words, and then realize that everyone else is dependent on them financially, socially, emotionally.”

Maintaining staff morale can be as simple as bringing in lunch or asking if they need anything for their homes. Simple acts of kindness such as these can have a big impact, experts say.

Khubchandani researches self-destructive tendencies in healthcare workers, such as excessive drinking, and says that a failure to address staff concerns can lead to more incidences of these behaviors.

“Generally healthcare professionals have one or two different types of stressing factors, but now there's multiple factors,” he says.

A major part of maintaining staff morale and practice operations is urging staff members to stay home if they are sick and providing cross training so that employees can fill in for one another when someone must take the day off.

Another important facet of staff safety is ensuring everyone is trained on the importance of personal protective equipment (PPE) and proper hand hygiene, experts agree.

If a practice staff member contracts COVID-19 and is being treated in an outside facility, do not count that time off as part of their PTO, due to it being a work-related incident, says Owen Dahl, MBA, FACHE, a medical practice management consultant.

Price says that to protect his staff he was able to quickly develop a mechanism to allow his patient coordinator to access the scheduling system so that staff member could work from home. Dahl recommends a similar workaround for billing departments, but in that case a secure virtual private network is essential.

As a measure to keep both himself and his patients safe, Price says he has begun offering telehealth as an option. This takes the form of phone calls with patients seeking preoperative consultations that don’t need face-to-face time.

“The telemedicine option also gives a tremendous boost to ability to care for people. Even though it's not a huge thing for my practice, I think for many practices, it will be,” he says.

As the threat of infection becomes apparent across the country, physicians should be aware of how their patient flow can be putting people at risk and consider options to change check-in processes.

Dahl says that preparation for a possibly infected patient should begin when they call to schedule their appointment. “When a patient calls in, find out their symptoms indicate the virus, then ask the patient that when they get to the office, to call you and stay where they are,” he says. Staff can then go out to the patient and walk them in with PPE.

If that’s not possible, patients exhibiting symptoms can be brought in a back entrance to the facility so as to avoid the waiting room, Dahl says. In addition, infected patients should be seen and kept in rooms with negative air pressure and the room should be cleaned thoroughly before and after the patient is seen, Dahl says.

It is better, Dahl says, if patients can flow through the practice without congregating in the waiting room. If you must have patients in the waiting room, ensure it is stocked with alcohol-based hand sanitizer and tissues and PPE that may be used to slow the spread of the virus. Also, follow guidelines on social distancing by keeping waiting patients at least six feet apart.

Khubchandani advises asking the facility’s cleaning staff to beef up sterilization efforts, and don’t be afraid to seem a little rude about it. “It's not rude to educate your supervisors, subordinates and clients because that's what we're here to do now,” he says. “Anyone who seems to be at risk, educate them.”

Coronavirus practice guide, part 3: Addressing staff and patient concerns

Mobile health (mHealth) apps are exploding in number and popularity, a development that presents new challenges for physicians: How do they determine which among the thousands of health-related apps on the market will help their patients? And how do they receive and process data from these apps in a form they can use?
	
	To help answer those questions, Medical Economics spoke recently with Tom Malick, senior product manager at Rightpoint, a digital consulting firm whose services include app design, marketing and development. Malick has worked with mHealth app developers to help increase adoption of their apps, and many of the insights developed from that experience also apply to doctors and patients.
	
	A transcript of the conversation, edited for brevity and clarity, follows.   
	
	

 With all the mHealth apps available today, how does a doctor know, or go about deciding, which ones are going to be effective and help patients achieve their health goals?
	
	

: That’s a great question. I’d bifurcate the conversation about how to choose an app into two parts. One is the more technical part, things like privacy safeguards, regulatory safety standards, interoperability. The FDA is actually doing some work right now in certifying those base level things, but you definitely need to check those boxes.
	
	The more challenging part is determining what the app is supposed to do, and does it work for my patients? You can have apps that simply educate the patient, you can have apps that track biometrics and encourage actions based on those biometrics, they could titrate medications, they could assist with medication adherence, they could be related to a physical monitoring device.
	
	So there could be lots of things the doctors may want. But I think the thing people are really concerned about today is that we have  something like 10,000 baby boomers hitting 65 every day for the next 15 years. And many of them have two or more chronic conditions. And I think PCPs are struggling with how to manage that.
	
	To help frame that, look at pharma. In many cases when pharma releases a drug the FDA just looks for it to be better than the placebo it was tested against, and that it doesn’t harm the patient. I think doctors should use that type of thinking when they look at an app. Because what we’ve found is that the Hawthorne effect is very powerful. And the Hawthorne effect is that the act of measuring something means you’ll change your behavior. When you start to measure your steps daily you’ll start to walk more just because you realize you’re measuring it.
	
	That has a huge amount of relevance for clinicians. Just keeping people focused on their health in some way and to track it is really important. But here’s where the most difficult part comes in. How will the doctors leverage that data? In a scenario where a doctor has recommended multiple apps to a patient, currently they [the doctor] would need separate  login information for each of those apps to access that patient’s data. Clearly that’s untenable for doctors, most of whom are struggling just to find the time to review information in the patient’s EHR before the patient visits. 
	
	The other thing that is absolutely critical: Think about if you’re a patient with diabetes, and you’ve gone through six months of logging data, always diligently monitoring your blood glucose readings. And you get to your doctor’s office only to find out they didn’t even look at it. It’s pretty demoralizing. And you can’t expect the patient to continue monitoring after that.
	
	So I think there basically needs to be a handshake agreement between the doctor and the patient, in terms of setting expectations as to how the app will be used, and what data the doctor will look at. The timeliness of their readings becomes very essential in getting people to use that app.
	
	

So how does a doc get around that? Is it just by limiting the number of apps they recommend to an individual patient, so they don’t get flooded by data?

 I think docs would love to be able to navigate this world. But the truth is, they’re somewhat held hostage by their computer systems.
	Here’s an example. In the current EHR environment everyone says we’ve got everything electronic and it’s wonderful, but the vast majority of the data sitting in the EHRs is just faxed data that’s been scanned and entered into it, not structured in any way. And you may have faxes from 10 different providers of all your medical history that’s almost indecipherable by your primary care provider. And in that vein, they certainly don’t have time to actually structure all that data.
	
	For an app to be effective it has to integrate into the EHR and be consumable by the doctor in a way that doesn’t add to their administrative burden.
	
	

 I think a lot of people certainly want those apps to exist. I think a good example is Livongo, which has done a great job in terms of meeting the patient where they’re at, which is really important from a user experience perspective, but also understanding that they can’t just drop an app on a doctor and expect it to work if it’s not interconnected in the medical ecosystem.
	
	Apps that live on islands die on islands, so apps that kind of go it alone, it’s going to be really difficult to get doctors to use them.
	
	The other thing we should address is the reimbursement aspect. Doctors don’t generally recommend procedures and things that aren’t reimbursable. Livongo is an example [of an app] that’s now reimbursable on some Medicare Advantage plans. So those apps that integrate with the rest of the ecosystem are the apps that will really shine in the future.
	
	The real gold standard is where you have enough medical research, you’ve met all the privacy and security standards, and you’ve gotten to the point where Medicare is going to reimburse for your app. I think it’s the ultimate litmus test for whether a doctor should recommend an app.
	
	I think another consideration for whether doctors should recommend an app is its usability. Will the user love it? Some apps that are out there now, like Facebook and Twitter, are designed where people absolutely love and want to open them all the time. Don’t we want that in medicine, where someone who has diabetes can’t wait to open their diabetes app? For people with chronic conditions, the hardest thing for them sometimes is to confront that condition. And opening an app every day reminds them of that [condition].
	
	So that app needs to be designed in such a way that it’s inherently motivating. And I think when a lot of folks go to build an app they do it backwards. They try to back it into the existing system whether it be pharmaceuticals or remote monitoring or payment. And the apps that have really blazed a trail have said, ‘We’ll worry about that later. What we want to do first is to make sure that people love it and want to use it and stick with it.’ That motivating part is so important to the success of the app.
	
	

 The more consumer-oriented apps, like Fitbit, have somewhat pulled this off. They’ve married the wellness world with the killer app world, and have apps that people want to open all the time. And doctors have struggled about what to do with that data. The truth is that doctors are constantly triaging in their mind. The doctor’s going to focus on the obese patient with diabetes over someone who’s in fairly good health and walking 10,000 steps a day. That’s why some worried well patients end up being disappointed their app data isn’t being taken more seriously.
	
	

 Are there any particular types of patients we know are really being helped by health apps?
	
	

 It’s quite a mixed bag. It looks like some apps do virtually nothing, while others certainly help patients control their blood sugar, reduce their blood pressure and things of that nature. Often the apps that really do well struggle to make money. And some of those have gone away.
	
	That itself would be a great study, to find out how many apps that showed efficacy are no longer around today. And I bet that number would be alarmingly high. The  ability for someone to say, ‘I want to help a patient is a lot easier unfortunately than to get that intervention in medicine today, and that’s a shame.
	
	Do we know if any other countries are doing better than us? ---Germany has made a move recently that I’d love to see in the U.S: They’ve outlawed the fax machine. Someone asked me, what regulations could the U.S. government put in that would help apps thrive? And I would say getting rid of the fax machine would be the single most important step you could do. To me, the American healthcare system has a weakness.
	
	Our data chain is only as strong as its weakest link. And by allowing providers to fax unencrypted information indiscriminately from provider to provider has not pushed us enough to creating structured data. And this means there hasn’t been a demand side for app data getting into the EHR. Because there hasn’t been a push for getting rid of that weakest link in the chain.
	
	So policywise, in many ways the Europeans are ahead of us. In terms of technology, the overburdensome regulatory environment that they live in makes it more difficult to create apps and all sorts of technology in general, whereas in the U.S. we’ve been able to really blaze a trail. So maybe we could learn a little from each other.

Mobile health (mHealth) apps are exploding in number and popularity, a development that presents new challenges for physicians: How do they determine which among the thousands of health-related apps on the market will help their patients? And how do they receive and process data from these apps in a form they can use?

Finding mobile health apps that work for doctors and patients

Can your employee handbook get you in trouble? Many healthcare businesses have an employee handbook, or employee policy handout, but fail to update them on a regular basis. There have been a large number of changes to employment law over the past couple of years that have forced me to review these documents more closely.
	
	The handbook should be a general overview of your expectations while working in your business.  Sometimes you can get too specific in your guidelines for disciplinary action, which can tie your hands in situations when an immediate action would have been better for your business.
	
	Your handbook is an evolving document and should be reviewed every year after the Supreme Court has ruled on all pending cases and released all their rulings at the end of June. It is not intended to be a comprehensive list of rules, but rather guidelines about how you expect employees to conduct themselves in your business. Here are some items you should be sure to include:

Do you have a social media policy? If you have one, does it prohibit employees from posting negative comments about your business?
	You might be surprised to learn that you cannot prohibit employees from posting negative comments about your business on social media. You can prohibit the use of social media in the work area on business time. You can prohibit the use of company computers to visit social media sites. You should be prohibiting all employees from accessing their personal email accounts on company equipment.
	
	


	
	If your state has an at-will employment law, you should also have a statement that the handbook cannot be considered a contract and that you have the right to make changes in an employee’s status whenever you feel necessary.
	
	The National Labor Relations Board (NLRB) has been critical of these statements in 2016, stating that at-will statements may limit the employee’s right to engage in activity to challenge their at-will status. In other words, the employee might want to negotiate a contract that gave them better benefits or wages. So your statement should include that only the head of the company or organization can negotiate a change in an employee’s at-will status.
	
	The word permanent needs to be removed from your handbook. An example might be a statement that after probation the employee would become a permanent full time. That can be construed as generating a contract, so don’t use it in your handbook
	
	


	
	Do you have a huge list of things employees might do that would result in disciplinary action?
	
	You might want to review that process and delete the list. You might instead have a statement about honesty, ethics, respect and the attributes you expect from them rather than a long list of items they can’t do. Trust me, there have been legal cases won because the termination infraction was not covered by the list in the handbook. You should also have a statement that holds employees to a standard that they should refrain from physical contact, threatening behavior, or violence.
	
	


	
	Do you have a policy about your process and how you will track absences?
	
	Review this policy carefully. Less is nearly always better than extensive. Do you have so much detail in the policy, that in practice you never comply with all of the rules? That could cause a problem if an employee wants to fight a termination and takes your handbook to an attorney. You should always have a statement that your disciplinary process, while liberal in nature, could result in immediate termination depending on the seriousness of the infraction.
	
	Foul language is always grounds for termination, right? Here is an example: An employee discussion gets heated and loud in a room with a closed door and not witnessed by other employees, and the employee is cursing and making disparaging statements about the supervisor. You would think that this is a reason to terminate, but it appears the employee can use foul language and make disparaging statements about the employer and supervisor as long as they are not within hearing of other employees.
	
	That is exactly what happed in the case Banner Health System dba Banner Estrella Medical Center and James A. Navarro. The NLRB ruled that the employee’s behavior in using foul language was not threatening, and an employee should be able to have a discussion about workplace issues.
	
	So be careful about your documentation when an altercation occurs. If you felt threatened by the employee’s behavior, make sure that is included in your disciplinary document.
	
	


	
	Do you have a policy that says harassment should be reported to the manager or supervisor?
	
	Just keep in mind that the manager/supervisor could be the person harassing the employee. You might want the employee to have the option of reporting to any manager. They need a way to report that does not affect their job in any way, so the reporting might be to a manager of a different department, or a supervisor in a different area.
	
	The handbook should make clear that you will not tolerate harassment, and if any employee experiences or observes harassment it should be reported immediately. The last thing you need is for a terminated employee to complain about unreported harassment and then enlist another employee to confirm their statement. Since your handbook should require that both employees must report harassment immediately, it would be more difficult for an employee to win a legal case if it was not reported until after the employee was disciplined.
	
	


	
	Have you reviewed your benefits to make sure they comply with federal and state laws?
	
	After the U.S. Supreme Court ruled that same sex marriages are legal in all states, many employers did not look at the wording of their benefits contracts. Several cases were brought against employers for having an insurance policy that did not cover same sex spouses.
	
	If you do not have enough employees to be impacted by the Family Medical Leave Act, leave it out of your handbook and state you are not required to offer FMLA benefits. If you do have to comply with the FMLA, make sure your employees are told who to contact and that they must fill out the proper forms in order to be eligible.
	
	Look at items like bereavement leave and make sure you have taken into consideration same sex spouses.
	
	

7 Vacation, sick leave, personal time off (PTO)

Does your handbook explain specifically how these will be calculated?
	
	Whether you choose vacation and sick leave in your business or PTO, you need to document how they will be calculated and when the employee will be eligible for these benefits.
	
	The handbook should also state whether any benefits can be carried over at the end of the year, or if employees must use or lose benefit time. If your policy allows some leave time to be carried into the next year, then that should be specified in the handbook. It should also address whether leave time survives termination of the employee.
	
	The handbook should not spell out the specific insurance coverage for healthcare. It should only specify that you offer health insurance and a 401K plan if you offer that. The handbook should tell the employee when they are eligible for benefits and have a statement that the benefits could change at any time.
	
	Each year you should give the employees a separate benefit document that covers the specific information about insurance coverage and scheduled vacation days. That way you can modify as needed without requiring employees to read and sign the entire handbook again.
	
	


	
	Does your handbook prevent employees from discussing their pay with other employees?
	
	The NLRB has ruled that companies cannot ban employees from telling other employees how much they are being paid. These rulings are generally aimed at large companies with many employees, but your handbook must be consistent with the current law in your state as well as the latest rulings from the NLRB. The motivation behind this ruling is that when employees have a complaint against management, they need the right to collect data to support their grievance. As a business owner, you should review the handbook yearly, at a minimum, and consult your company attorney to review any changes to make sure you have adequately protected your company from employee lawsuits. Do not just go on the internet and get a do-it-yourself handbook. Your handbook should be common sense guidance to your employees about your specific business, and these handbooks that are available online are not written to match your individual business.

Carol Gibbons, RN, BSN, NHA, is a healthcare business consultant.

Can your employee handbook get you in trouble? Many healthcare businesses have an employee handbook, or employee policy handout, but fail to update them on a regular basis.

8 tips for avoiding employee handbook crises

A recent article by Victoria Knight of Kaiser Health News chronicled the declining interest in primary care (i.e., general internal medicine, family medicine and pediatrics) by medical school graduates.
	
	Of 8,116 primary care post graduate training positions, only 42 percent were filled by graduates of U.S. medical schools. Osteopathic graduates (DOs) and foreign medical school graduates (FMGs) made up most of the remainder.
	
	There is nothing negative about DOs and FMGs being primary care physicians (PCPs); the question is why don’t more U.S medical school graduates enter primary care? This issue is critical because the American Association of Medical Colleges (AAMC) projects that there will be a shortage of  21,100 to 55,200 PCPs by 2032.
	
	Knight suggests a few reasons for the declining interest:

Specialists typically earn twice as much as PCPs (although the median PCP income of $223,000 is not trivial.)

Many medical schools overtly or covertly encourage graduates to pursue specialties.

PCPs must spend an inordinate amount of time completing the electronic health record (EHR) and other insurer-required paperwork.

76 percent of medical students graduate with debt. According to the AAMC, the median debt in 2018 was $200,000.


	
	Knight’s article was well researched, written and thoughtful, but like so many, she missed the most important point. Medical students are smart.
	
	They look around and realize that for less money, they get more responsibility and longer hours. And they have to earn that money by seeing far too many patients per day-24-30 patients, with an average visit of only 15 minutes-less when actual face time is considered.
	
	With less time, students realize that they will not be able to practice comprehensive medicine as they are trained and desire to do. They realize that complicated issues that can’t be solved in a just a few minutes will need to be passed on to a specialist, substantially raising total healthcare costs. They also realize that they will not have the time to develop a close, trusting relationship with their patients and hence lose the potential for trust and true healing.
	
	With the added burdens placed on them by insurers that further dilute time with patients, the end result is a simple decision-choose another career path even if primary care would otherwise be their preference.
	
	

Underestimating the value of primary care


	
	There is an insidious misunderstanding of primary care. Most people, including all too many physicians and medical school faculty, think of primary care as treating only the “simple stuff.” That explains in part why they are prone to tell aspiring medical students that they are “too good for primary care.”
	
	In fact, the well-trained and experienced PCP can handle most of the complex chronic illnesses that currently beset the American population-diabetes, heart failure, obesity, hypertension, etc. These are the diseases that consume 75-85 percent of all healthcare dollars. They are also adept at addressing most of the mental health problems, including anxiety, which accompanies or drives a large percentage of medical visits. Of course, they know when it is appropriate to refer a patient for more specialized care.
	
	Why is it necessary to see so many patients per day? Insurers reimburse PCPs at low rates and do not appreciate the value of involved history taking, thorough examinations and the time spent learning and thinking. Insurers have also burdened the PCP with innumerable new requirements that add to the burden of ‘feeding’ the EHR and that further take time away from patients. Billing and coding have driven up office costs dramatically.
	
	The result is that PCPs need to see more and more patients per day to cover their costs and maintain their incomes. Frankly, it is a non-sustainable business model. The result is that many PCPs are retiring early, others are selling their practices and working for the local hospital, while others are just keeping their heads down and getting burned out; over 50 percent have some objective evidence of burnout today, which negatively impacts not only doctors but their patients.
	
	For those patients whose PCP follows the 24 -30 patients per day model, the result is less comprehensive care, more referrals to specialists, inadequate coordination of care, more tests, more ER visits and far less satisfaction.
	
	


	
	There are a number of possible approaches to solve this crisis in primary care. One is for a physician to reduce his or her practice size from the usual 2,500-3,000 patients to 400-800 patients, depending on the demographics of the patient population (practices with more seniors can see fewer total patients). The physician or nurse practitioner offers same-day and next-day appointments that are as long as necessary, plus prompt access by email and cell phone. Patients receive a comprehensive annual evaluation along with special attention to wellness and prevention.
	
	Several different models use similar fundamentals:

Direct primary care (DPC), an approach that is usually the least expensive but entails seeing more patients

Concierge medicine (which is more expensive but physicians have fewer patients in their practice) 

In most of these models, rather than accepting insurance, PCPs typically charge patients an annual or monthly fee that covers some or all services. DPC allows adequate time per patient, better attention to chronic illnesses, coordination of care when a specialist is needed, 24/7 access, and, most importantly, the opportunity to develop real trust. The result is significantly improved quality of care.
	
	Add to that greater patient satisfaction and less physician burnout. Not bad. And it lowers the total cost of care because it reduces specialist referrals, tests, imaging and ER visits, and often lowers hospitalizations. Said differently, the higher cost of these forms of primary care is more than offset by lower use of more costly care.
	
	When students see that a DPC type of practice allows them to give excellent care, create deep interpersonal trust and have a real impact on people’s lives, have a decent home life and still get paid a good income, far more of them will choose primary care.

Stephen C. Schimpff, MD, MACP, is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and author of Fixing the Primary Care Crisis and Longevity Decoded – The 7 Keys to Healthy Aging

Why don’t more U.S medical school graduates enter primary care? This issue is critical because the American Association of Medical Colleges (AAMC) projects that there will be a shortage of  21,100 to 55,200 PCPs by 2032.

April 25, 2020 edition

Coronavirus practice guide, part 1: Financial steps to save your practice during the coronavirus outbreak

Coronavirus practice guide, part 2: Crisis could boost telemedicine use

Coronavirus practice guide, part 3: Addressing staff and patient concerns

Finding mobile health apps that work for doctors and patients

8 tips for avoiding employee handbook crises

How to fix the primary care crisis