AMGA CEO Council Meeting: Staying Open as COVID-19 Nears Peak

AMGA COVID-19 Resources
 

Presentation Summary
March 25, 2020

This summary is based on a presentation to the AMGA’s Chief Executive Officer/Board Chair/President on March 25, 2020. For more information about the CEO Council, please click here.

Presenters: Anthony Viceroy, Chief Executive Officer, Westmed Medical Group (March 25, 2020)

Anthony Viceroy: In New York, this is a crisis like I have never seen before. Here are some latest stats which probably are outdated in the last hour. In the state of New York, we have over 30,000 confirmed cases, making us the epicenter for this virus. In Westchester County, where we are located, we have just under 3,900 cases and only one death. In New York City, we are up to 16,000 cases and 200 deaths, with 3,800 people hospitalized. Not enough beds means our local hospitals are stretched very thin with having to come up with 100% more capacity in their hospitals.

Unfortunately the apex in New York is expected in next 21 days. Height is in mid- to late April, and hopefully we will see it subside after that, but no guarantees.

Leadership

Leadership communicates regularly with staff, although we have more questions than answers. Some things I’ve learned: Remain calm and in control because all eyes are on you. Stay positive but confront reality. Over-communicate—it is what people hear, not what you’re saying. Try to keep your messages clear and on point.

I have looked to others in the organization to step up. At first, I thought I could do more then what I am capable of. So, we are trying to divide responsibilities and have a call at the end of the day to bring everything together. I am in constant communication with our physicians with the unfortunate news that this is our new normal. It is not the time to be fractured and unglued.

Inventory

Westmed is in our fourth week, and the first thing we did was start planning around inventory. Our focus was not to shut down completely because if we ran out of PPE, it would stress the hospitals even more. We closed two large sites to minimize spread and protect inventory. I am trying hard to secure N95 and L3 masks. Every night, we have an inventory count and are looking at the burn rate to preserve inventory. At the same time, I shored up our finances and a secured a line of credit as soon as the outbreak happened here because banks will start to stall giving loans.

Strategies to Stay Open

We decided to pay employees for two weeks as things played out. Once the Senate and House bills pass, it looks like $130 billion is to be shared with health systems, and we are looking at how this will all play out. Once our inventory comes in, hopefully in next week-and-a-half, we will look to reopen sites and balance in-person visits with telehealth.

We moved aggressively to telehealth, but because we had to do it fast, there were glitches. We tried to put all providers on at once. Some patients are still not able to log on, even though we shared instructions. If you are in a place where this hasn’t hit yet, I would urge you to get telehealth up and running now to make sure patients can log on ahead of time. We told employees about our PTO guidelines and they need to be here for patients, but we will follow federal mandates regarding furloughing.

We reduced physician draws for March by 40%. As mandated by New York, we stopped all elective surgeries. I am talking with local hospitals about leasing our ambulatory space and staff to them, as they need more capacity and this could be more cash for us.

We’re reviewing all vendor contracts to see if we can renegotiate or extend payment terms or reduce pricing. We are trying to reduce premiums on malpractice insurance since our physicians are not practicing.

You have to be extremely flexible because the plan keeps changing every few minutes as more information comes in, but we took the position that we want to stay open for the community and minimize hospital burden. As this virus continues to peak, we will have challenges of providers and staff who are sick. We are constantly looking at staffing and how we are going to mobilize teams, and we are looking at sick vs. not sick clinics. The challenge with that is you have patients who say they aren’t sick but show up sick, and no one wants to go to the sick clinic.

All this is real-time management, and our staff has done the best they can to stay ahead of this. In New York, this will get more challenging in the next few weeks before it gets better. It’s important to keep reminding physicians and employees of this. As the President and others stated, this is a war and this is a health crisis with real financial impact—we are trying to fight two sides of a war at the same time. Some smart decisions at the beginning will help protect us through this rough patch.

Question: What are your approaches for PPE? How do you manage the supply? Or do you have any workarounds you can share?

Viceroy: I can tell you I centralized all inventory immediately because I recognized that as this crisis got worse, I would start to see PPE go missing. I went around to all sites and locked up inventory so that it would need to be signed out each day. This gives strict accountability to what is going out and who it is going to. Our corporate location has the reserves. That way, I can distribute to sites as needed. I didn’t want to take any chances since it is getting harder and harder to get PPE in. Preservation is what will allow us to stay open.

Question: Can you tell us the demographics of your organization? Are you primarily outpatient, specialty, independent, etc.?

Viceroy: All of the above. We are a 350,000+ patient multispecialty outpatient practice that has 13 locations. Our clinics tend to be larger in nature, anywhere from 80,000 to 120,000 square feet.

Question: When you talk about furloughing your employees, what decisions are made and what percentage overall have you decreased? Also given the restrictions on coming to work with fever or cough, are you seeing a lot of people quarantining themselves?

Viceroy: At first we tried to follow the guidelines of our local health department. Our challenge has been as the virus gets worse, their position is also changing. If someone was suspected, they should be quarantined for 14 days and everyone around them quarantined. But we realized you would have no one left to work. So, only if you are showing symptoms, you quarantine yourself, and the people around you don’t need to quarantine unless they are symptomatic.

Then about a week-and-a-half to two weeks ago, we saw people who started to be a carrier and asymptomatic and still spread the virus—they flip-flopped back and forth—and we haven’t got a true definition from them. We have taken the position that if you are sick, you will stay home, and we are practicing all social distancing and everything like that.

Our corporate headquarters is working from home and a lot of patient volume has decreased, so our clinics can spread out and the patients in the waiting rooms are not one on top of another. We screen all employees and patients at the front door for fever as well as do a visual check to see if they are coughing and how they feel. We are trying to have those patients who are truly sick and need COVID testing get that test. We aren’t doing testing because test kits are hard to come by and there are so many locations in New York that do testing that it is a better use of our time not try to conduct the testing.

We plan to take a look at the legislation and make some tough decisions about the furlough process. A lot of hospitals and people on the front lines who are taking care of patients with respiratory issues are looking for nurses and physicians. So, I am in conversations with them to potentially have a service contract to lend out employees who want to go there and they will pay me some kind of cost. We would furlough employees who don’t want to do that and whom I don’t have a need for. I need to understand better what kind of compensation would be coming their way.

Question: How are you supporting people from a wellness or burnout perspective?

Viceroy: Our behavioral health department has been working overtime, as everyone has been, to try and come up with wellness and mindful programs to try and alleviate stress. I think initially we were ahead of the curve, but this is our fourth week so we are addressing this. Starting out, everyone had a bunch of energy and four weeks in, I can share that it tends to get a little exhausting and what we are trying to do now is try to give people little breaks in the day, even if it’s for an hour or two, to collect thoughts and take a deep breath. Lots of physicians and employees have families and kids at home and it’s important to be available for everyone, so we are just going to have to manage that as we go because I am expecting this to be at least another four to six weeks, probably six to eight weeks.

Conditioning will be the next phase; we saw a lot of energy the first couple of weeks but now conditioning is critical because this is a marathon. We are going to have burnout if we keep going at that fast of a pace. We have gone a little deeper on our bench. You know leaders can be at any level, not just your title, and we are taxing those individuals who can step up and have capability to do more. We are trying to spread out work evenly and make sure everyone is involved and not overloaded so we can keep going.

Question: Are you using criteria for extended use of surgical masks as well as PPEs in terms of decontamination?

Viceroy: We are handing out masks each day in our urgent care. They all get all N95s. If they are swabbing the patient, they have to change the mask. The spectrum goes from one end to the other end. One health system in Connecticut is reusing masks and collecting them at the facilities at the end of each day to sterilize and redistribute them. I think it depends on where you are in your PPE to make that decision.

I have had a tremendous amount of L1 and L2 masks come in. When we don’t have the sick patients, we been distributing those L1 type masks. Some patients feel better knowing they can come into clinic and everyone is masked, and other patients get freaked out because they automatically think everyone has the virus. So it has been a challenge to get to a comfort level. So far, we are masking everyone who comes through the door because we are in the hot bed and the threat of spreading this is very real. So far, we have been letting everyone use their mask for one day, and if I get dangerously low, obviously I will have to come up with other options. I am waiting on a large shipment coming in in the next 10 days. If I get that shipment in, I should be good for at least another few weeks.

Question: Have you put any policies in place for your physicians at 60 or 60+ and those physicians who have preexisting conditions, such as lung disease or other things?

Viceroy: We have strongly encouraged them to not come in, but haven’t made it a formal policy yet. I think most physicians who are in that demographic understand the risks. I had one physician last week tell me he was seeing two patients and then he was retiring on the spot. So, many within that criteria have been staying home; to the extent they can do telehealth visits, they are. Some of them want to come in and keep working or need to keep working for financial reasons. On the other hand, the New York governor keeps asking for any physicians and nurses who are in retirement to come out because he is afraid there won’t be enough staff to man the hospitals. For now, we have basically asked everyone to be more cautious and take the proper precautions rather than putting yourself in a predicament to get seriously ill or die.

Question: How are you handling physician compensation during this time? Are you setting any type of floor for physicians?

Viceroy: We have a productivity model and we set the draws in January of each year. When we get to each quarter, we do a reconciliation. In the midst of everything going on, the whole month of March we have been hit with this. I did a 40% reduction in draw across the board. Instead of quarterly, I will be looking at our volume each month and reevaluating whether or not 40% is appropriate. I didn’t want to go deeper than 40% because my goal is to try and keep our clinics open. As scary as this virus is, there are still a lot of our patients who don’t have the coronavirus and still need to be seen. In a multispecialty practice, it is very challenging to close down orthopedics or ophthalmology because patients still need care and need to be seen. Our patients with diabetes still need to come in, and wounds still need to be attended to. While I still have a lot of AR, I wanted to be ahead of the curve and reduce the draws for the month of March.

Question: From the standpoint of cross-training, what have you done? Are you using any of the critical care skills and retraining or cross-training?

Viceroy: We haven’t done that yet because, unfortunately, I haven’t had time to plan. We have been drinking from the fire hose here. But as we start to see things materialize a little bit clearer, we will have to probably cross-train a little bit. We have taken the position that it is all hands on deck. And to the extent that we can leverage telemedicine, that would be the preferred method. Our payers are paying us par for those methods. We can do prescription refills, and for those patients who just need to talk to their doctors, we can do that via telehealth. If it gets to a point where the hospitals are overrun and need help, I am working on agreements with local hospitals now. We are independent, so we would have an agreement where we would rent out physicians and nurses to them.

Question: How many of tests are coming back positive? How many of your staff or providers are testing positive?

Viceroy: We had three providers and two employees who have tested positive. So out of 1,500 employees, we have had five. We have not been able to get tests done here, so basically if you have symptoms—fever or cough—you call in and we direct you to the nearest place to get tested. The problem is: with some tests you get results within 48 hours and others take longer than a week. I had one case where someone had it, but by the time they got the test results, they were feeling much better. So, testing has been a little insane, and since the rate of testing accuracy is 70% accurate, 30% could be false. At the end of the day, if you are showing symptoms—regardless of whether it is flu or COVID—we are taking the stance that it is COVID, so get screened and then we will track you from there. Most of our patients who have called in have been treated from home, but there are a few who are in hospitals and have been on ventilators.

Question: Are you coming up with other innovative care delivery models besides telemedicine? Are you thinking of doing home visits for elderly or chronically ill? How long are you putting off time-sensitive well care, like newborns, children under the age of three who need vaccinations, etc.?

Viceroy: We created a pediatric sick clinic so we can centralize care for those children in one location. We would still be open in other locations for non-sick kids to come in and get vaccinations and stuff like that. OB is a little more challenging, and we are still bringing in moms who need to be seen. We are working with hospitals now to try and figure out the complexities of delivery, as they all need more space for the projected number of sick people who will be coming in. I don’t have a firm answer on it now, but we are working with the hospitals on maternity. For other forms of delivery, at this time I just don’t have the excess capacity. We probably have about 20,000 Medicare patients, so if half of them were of the stage where we need to take care of them, I don’t have the manpower to take care of 10,000 patients in their homes. This is why we are quickly trying to open up our clinics and section out clinics to treat those patients and ensure it is a sterile environment for them, and we are taking all the necessary precautions.

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