As COVID-19 continues to take a toll on the State of Florida, the entire healthcare community is straining to meet the demands of the sickest patients. Independent physicians are faced with shortages, uncertainty and changes to regulations and standards on a daily basis.

It was never easy, but now, healthcare providers are staring down a surge of patients that will almost certainly overwhelm the system before the flood of disease begins to ebb.

At the same time, according to reports from ProPublica, and others, employed doctors and nurses on the frontlines of patient care with PPE shortages are facing pay and benefit cuts. 

Orlando Medical News talked with two champions of independent physicians to find out what they see as critical needs and strategies for survival of their medical practices.  

Larry Jones is the Executive Director of the IP Network, and CEO of HPOF Holdings, LLC, a healthcare company headquartered in Maitland, Florida.

As the CEO of HPOF Holdings, his company's main mission is to preserve and protect the independent practice of medicine. 

Larry has been on both the payer and provider side of healthcare. He served on the Business Advisory Board of Seminole County Public Schools for 12 years, representing the insurance committee and 9000 employees' lives and almost $60M in premium.

He is a member of the National Association of ACOs. He is a founding board member of the Florida Association of ACOs.

His organization currently runs eight Multi Specialty IPAs, an MSO with two Medicare contracts, and also manages four ACOs with MSSP contracts with CMS.

Marni Jameson Carey is the Executive Director of the Association of Independent Doctors (AID) in Winter Park. A national nonprofit trade association with 1000 members in two-thirds of the United States, a national nonprofit, nonpartisan trade organization dedicated to helping reduce healthcare costs by keeping America’s doctors independent.

OMN: What steps are you taking with your members to help keep their practices running?

Jones: First, this past week, we collaborated with all the major payers: CMS, Blue Cross, Cigna, Aetna, United, Humana, Simply, and CarePlus. We obtained all their telehealth/telemedicine information on how to deal with their patients telephonically with a virtual appointment and also billing codes that apply. Our doctors are currently in the process of rolling out and seeing as many patients virtually as possible. That's a big step right there.

Second, we do have some offices that have set up drive-through areas in their parking lots to take care of their routine patients and to not have those patients come into the office. That’s working well. We’re doing that for maintained chronic illnesses that you just have to get a checkup every now and then to come in and you get your meds renewed, reordered, that type of thing. We've got a lot of docs that are trying to do that in a drive-through manner at their offices on their property. Independent physicians are looking for every way they can to make sure that they are still communicating with their patients.

Next, we do have some offices that have set up shorter hours to see patients. We see some doctors close at noon because they're running out of supplies. Some offices have closed completely during this time.

Unfortunately, some practices have had to lay off as much as half their staff due to the slowdown.

OMN: Generally speaking, what are you, what are you hearing from, from the doctors you've been speaking with?

Carey: They're very worried. They don't know what’s, going to happen to their practice. The ones who are doing well are the direct care doctors. They don't have to worry about getting reimbursed by anybody, so they're in pretty decent shape. I'm getting calls from surgeons and other specialists that have various independent centers that are not affiliated with hospitals, like vein centers and cardiologists who don't do surgery but see patients, and no one's coming in. Surgeries are being canceled, staffs are being laid off, income is drying up, and they don't know where the relief is going to come. They're very concerned.

OMN: How are practices set for weathering this for six to nine months?

Jones: The specialists certainly have a greater ability to weather this storm than the primary care physicians do, mainly because of the higher income. They're also making use of telehealth and telemedicine to keep up with their patients as well.

This era of moving from fee-for-service to fee-for-value, is going to be a challenge over the next few months. We're graded on closing care gaps, maintaining costs, making sure that the right care at the right place, at the right time for the appropriate amount of cost is delivered. We're not sure what this pandemic is going to cost in that algorithm formula for value-based care. It's still to be seen. Fortunately, CMS has announced that they're going to drop the requirements for MIPS reporting for 2020.

The thing about our independent doctors, particularly IPN, our physicians are in major commercial ACO contracts and we're also in MSO, Medicare Advantage contracts. All of those require things like HETUS, STARS, quality metrics, care gap closure. It's going to be more difficult right now with the offices completely bombarded to get it done. I think the feds are realizing this and I think you're going to see some alleviations in some of the policies, at least during this time period.

OMN: You mention layoffs.. are they reporting a lot of them?

Carey: Doctors are probably going to be able to weather this personally through a few missed paychecks, but it's a cascade effect we all need to worry about. Doctors employ lots of people. I have a doctor who has had to layoff a third of his staff. Another doctor I spoke to yesterday has a staff of 12 that he said are absolutely wonderful people. He would hate to lose any of them, and he doesn't know how he's going to be able to keep them. If a doctor isn't working, isn't seeing patients, isn't doing surgery, isn't bringing in revenue, the trickle-down effect is the staff gets impacted and may need to be laid off. One doctor has told me he canceled 27 surgeries. The hospital where he operates normally would have had all of these elective surgeries, but now all those beds are empty that would have been filled. A whole group of employees at that hospital have been told to stay home…so the patients suffer, the staff suffer, the hospital employees take a hit. It's a cascade effect. We all need to care because they've just impacted a hundred people.

OMN: Are there ways you are looking at helping offices keep staff?

Jones: One of the things that IPN, our board, our management team, are very concerned with, is that we know that certain offices are going to be laying off staff, and we're trying to come up with some kind of a program that we can assist these people that are being laid off to still have some income during this time period. What that's going to look like or how that develops or the timeframe for that developing, we don’t know, but we are certainly having those conversations now.

OMN: With are the pressures on primary care physicians, do you see any of them merging practices down the road?

Jones: No, I don't see anything like that happening. We're going to do everything we can to support our physicians and give them the tools and the backup necessary. In fact, IPN has a relationship with a GPO, OneAccess, who we have already contacted to ask them to give our doctors different ordering processes to be able to still maintain a supply of masks, gowns, hand sanitizer, hand soap, and that type of thing. We’re just trying to keep the doors open with supplies for our independent physician practices.

OMN:  Do you have some specific steps that you're recommending to your practices to help them survive?

Jones:  We're recommending that they still continue to manage their chronically ill and patients that show up thinking that they have coronavirus. With the other patients, they need to postpone their appointments if it's just a routine appointment and schedule it down the road, or if it's a chronic situation, hold it by a telemedicine virtual visit.

I think you're going to find that the primary care guys are just going to be overloaded and overwhelmed. The specialists, I would say your respiratory, like pulmonary, allergy, maybe even a cardiovascular with COPD and CHF, those are going to be the ones that are going to be completely overwhelmed right now.

Then the other idea is to just push it as fast as they can but know that IPN's there for them and our physicians. You can't imagine the number of calls we’re getting. We have 1500 physicians in 11 counties, which includes 475 primary care and the balance is all multi-specialty. We are doing everything we can to reach out to them.

OMN: What are you suggesting for the next several weeks?
Carey:  My best advice is lean on your advisors. It's very different state to state. It's very different practice to practice and it's very different specialty to specialty. This is not a situation where one size fits all.

You really need to lean on your administrator and your tax accountant and your legal team to find out what you can do to position yourself to get through this

I just want them to hang tough. It's frustrating to me that there were $150 billion allocated to hospitals in this stimulus package. But I don't see where that's trickling to independent doctors. The hospitals have more unsecured assets. In our own town, they have $4 billion in unsecured assets that could take them for a long time and our independent doctors don't have those kinds of reserves. It's a little frustrating to see so much stimulus going to hospitals, although I know many of them are going to be overwhelmed and are going to need resources, but they have a lot of resources the independent doctors don’t. I am concerned that independents are going to be underfunded, under equipped, and they're going to have a little harder ride through this time than some of their cushier counterparts, but I want them to stay strong and independent because America needs our independent doctors.

Protecting Your Practice During the Coronavirus Pandemic

       10 Things to Remember

A Discussion with the Integrated Independent Physicians Association (IPA), on protecting your practice: 

1. PPE supplies - order from multiple suppliers, not just your normal vendor. 
2. Utilize Telehealth to communicate with regular patients to

• Maintain management of chronic patients, prescription refills, etc.
• Maintain consistent office practice revenue, as most payers are allowing same level E&M codes billing for telehealth visitsand waiving copays  

3. Set up drive through in your parking lot for low level patient visits, prescription refills, etc.
4. Hospitals are asking for volunteers, be aware of your specialty malpractice coverage and boundaries.

• Many physicians have asked advice on personal protection assurances from the hospitals,that are requesting additional services and help. 

5. Email or text to your entire patient base announcing thewaiving of copays and assuring them, that your practice is open and accepting patients  
6. Ask patients to call your office BEFORE they go to ER or hospital. This will save them time and money and avoid additional exposure for them. 
7. IPN has sent out Telehealth Guidelines for most payers, as well as an interpretation of the Surgeon General’s order on using Telehealth services
8. IPN has requested the payers eliminate copaysfor patients seeing our Independent PCPs and Specialists, in our Value Based programs. This will incentive patients to call their PCP vs. just going to the ER or hospital.  
9. Maintain contact with your Hospitalist Representative for your patient admissions 

Courtesy of Integrated Independent Physicians Network

Please call the IPN office, if you have questions; 407-475-9213