Flexibility, Innovation Key to Practice Management During Pandemic

Tara Haelle

October 09, 2020

Practice management is the responsibility of every pediatrician, and leadership is more important than ever in a crisis like the COVID-19 pandemic.

"Ultimately you have a critical role in ensuring that your practice remains sustainable so that you can continue to deliver great care," Sue Kressly, MD, a retired pediatrician from Warrington, Pa., said at the virtual annual meeting of the American Academy of Pediatrics. "None of us escaped some impact of the COVID crisis, and many of us are going to experience lasting change."

Kressly and Suzanne Berman, MD, a pediatrician in central Tennessee, presented a live online session on how the pandemic is affecting practices and how pediatricians can effectively address those challenges.

Three Ways a Crisis Impacts Practices

"When a practice experiences a crisis, it really exposes what your practice is made of, for better or for worse," Berman said. "The COVID crisis has been profound and broad and long enough to really stress the core tensile strength of practices along at least three axes." Those are staffing, financial health, and partnerships.

It's a normal human response to enter survival mode during a crisis, so staff management becomes more important than ever. Some things to consider are whether you have a truly collaborative team culture in your practice and whether you're really listening to the staff's struggles and suggestions.

"Staffing challenges can be very difficult," Berman said. "Permitting staff to work from home is the single biggest thing you can do when staff needs to self-isolate."

Financially, most medical practices have adequate cash on hand not to have to pay close attention to the numbers, Kressly said, but if physicians are looking at their books for the first time during a crisis, they have no way of knowing what their baseline expectations should be or how much to worry about their finances. It's important to understand your practice's or department's budget.

Jesse Hackell, MD, a private practice pediatrician in a suburb of New York City and vice president of the New York AAP Chapter 3, attended the session and appreciated this point on finances.

"In order to provide good quality care to kids, you need to be financially successful because otherwise you'll close your doors," Hackell said in an interview. "It's making yourself available to be able to provide care."

Stressors among partners during a crisis arise from responding to the challenges of the crisis, such as who should be impacted by pay cuts or furloughs, how to account for overhead, how to distribute revenue and how to divide the work equitably. Other issues include how to protect higher risk providers fairly and how to shift schedules or case load based on unforeseen events, including quarantining.

"There is no 'fair' in a crisis," Berman said. "We must use the equity paradigm to be sure everyone has what they need to survive and have the best outcome possible."

The speakers also discussed the importance of a practice's situation before the pandemic began, a point that resonated with attendee Jason Terk, MD, a pediatrician who practices in a large pediatric health care system near Fort Worth, Texas.

"Just like the pandemic impacts the health of people in different ways based upon their baseline health, the pandemic impacts practices in different ways based on the practice's baseline health," he said in an interview. "If you had good operations, a good culture, good communication and all those other good indicators of practice health before, then you stood a much better chance of surviving the pandemic as a practice than practices that had weaknesses before."

The size of a practice did not necessarily predict the impact of the crisis, Berman said. Rather, practices with good patient engagement, active recall programs, and good fiscal planning did better.

"One of the most useful takeaways is that flexibility is key," Hackell said. "We had never seen anything like this before," he said in an interview. "From the start we had no idea what was going to work. Try something and see if it works. If it fails, try something else. We were all operating blind here."

The focus of most practices in the spring was on well visits, chronic care follow-up, and telehealth. Going into fall and winter, innovation will be necessary to provide appropriate care for all children while keeping in mind that the choices pediatricians make will have long-lasting implications for their staff and patients. The speakers stressed the importance of communication and transparency within the office team and to patients and the community.

 Hackell appreciated the speakers' point that kids need care, and pediatricians need to meet that need.

"Kids need well care and immunizations, and kids get sick and need sick care," he said. "Parents need a lot more reassurance during times like this. We need to be able to provide that care and be sure that we do it safely. To give the right care at the right time in the right location is key."

Making Practice Adaptations

In balancing risk and access to care, Kressly described the importance of multiple interventions, including managing some patients out of the office and making physical changes, such as putting in physical barriers and eliminating waiting rooms.

"Many practices are highly focused on PPE [personal protective equipment]," Kressly said, but even Centers for Disease Control and Prevention guidance emphasizes that PPE is the last line of defense. "There are many things we can do to protect our teams and our patients, and we know that not one single adaption is going to be 100% effective. But like the Swiss cheese model indicates, when you layer all of these efforts on top of one another, many defenses allow for the protection of the majority of people."

Other changes include restricting office visitors to one per patient, implementing social distancing, requiring visitors to wear masks, and considering alternate locations for visits, including car and parking lot visits.

"No idea is too crazy, and some of the best ideas come from your staff," Kressly said. She also recommended asking families where they feel most comfortable meeting.

"Don't make any assumptions about where they want to be seen, but ask and together decide where the patient can most safely and effectively be given appropriate care," she said.

Kressly also noted the new CPT code, 99072, that can be used to bill for "additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other nonfacility service(s), when performed during a public health emergency as defined by law, due to respiratory-transmitted infectious disease."

Pediatricians should think of ways they can remove barriers to access, such as adjusting no-show cancellation penalties and adjusting practice policies as needed when things change. "Avoid creating a culture where families do not disclose all information for fear of not being seen," Kressly said.

A slower pace because of delays and hiccups is also normal at this time, Berman said. "If you feel like you're just not as efficient as you were prior to COVID, it's not just you," she said. "It's true. Everyone has to grapple with new things now. It takes longer."

Things that add time include remote check-in and paperwork, more time to don and doff PPE and disinfect, dealing with technology failures, adjusting to new procedures or policies, and the general mental fatigue of adhering to PPE best practices. Patience is vital during this time, Berman said.

Several ways to improve efficiency include cutting out unnecessary steps, using standing orders and Advance Beneficiary Notice of Noncoverage (ABNs) for flu vaccinations, keeping credit card numbers on file for contactless payment, and considering the clinical and financial value of lab testing before ordering it.

"Effective triage helps patient satisfaction, access to care, and efficiency of your office workload," Kressly said. "Use technology where it's appropriate, but then add people where it's needed. Connections to caring people matter even more in a time of crisis."

The speakers also highlighted the importance of early flu vaccinations.

"One of the single biggest things you can do for value in COVID is to get your flu vaccine numbers up," Berman said. "Severely reducing the burden of influenza will help flatten the curve, it will reduce febrile respiratory illness, and it will protect your most fragile patients."

Two ways to do that include flu clinics and making a strong push for immunizations during the first 8 weeks after getting the vaccines. Berman shared numbers from two practices showing how many more total immunizations were done in the practice that began vaccinating in early August versus early September.

A Crisis Is an Opportunity

The speakers closed on an optimistic note that emphasized the opportunities that can grow out of the challenges presented by the pandemic, a point Terk elaborated on.

"One of the most important things is realizing how we can potentially use a crisis to transform our practices," Terk said in the interview. "As had been said before, a crisis is a terrible thing to waste. Those practices that have the gumption to innovate and find different ways to improve the way they provide care are probably going to be in better shape as we go forward."

Critical to that success is taking risks, he added.

"When you're innovating, failure has to be something you are permissive of because if you're risk-averse and failure-averse, you're not going to have the opportunity to grow and innovate, and this is another opportunity to innovate," Terk said.

He also stressed the value of learning from one another. "We need to help each other by sharing our good practices, and on the flip side, be open to learning from each other," he said. "Those pediatricians who are struggling need to be open-minded and open-hearted to understanding how we can operate our practices better and know that the things we think are barriers we can't change are probably things we probably haven't allowed ourselves to think about changing."

 Kressly and Berman recommended several specific actions for pediatricians to take:

  • Creating a SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis regarding your practice management response to the pandemic.

  • Articulating three goals for improving your understanding or the implementation of management in your practice.

  • Creating a working group to identify and implement ways to improve clinical work flow and communication strategies.

"Now is the time to meaningfully address disparities of access to appropriate health care and the impact of social determinants of health," Kressly said. It's also an opportunity to build meaningful relationships with patient families based on trust, science, and "true shared decision-making with health literacy in mind."

Kressly is the medical director of and owns shares in Office Practicum. Berman is the assistant medical director of and owns shares in Office Practicum, and is the owner of Script Doctor LLC. Terk and Hackell had no relevant financial disclosures.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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