EPtalk by Dr. Jayne 7/2/20

We had more craziness in the clinical trenches this week. Several of our sites ran out of COVID-19 testing swabs and we were told by vendors that shipments were being diverted to Texas, Florida, and Arizona. I’m not sure how we’re supposed to prevent outbreaks if we can’t test, but welcome to the world of supply chain shortages. It’s not like we haven’t had months to ramp up production, or that we aren’t unaware of the need to keep testing for the foreseeable future.

I’ve spent a good chunk of my professional career helping practices with capacity management as they transition from regular (long wait time) scheduling to open access scheduling, along with figuring out how to ramp up or down with EHR go-lives and upgrades. I’ve never dealt with anything like the capacity management needed to handle the unpredictability of COVID, so if anyone else has tips or tricks, I’m listening.

The New York Times also picked up on the issue of variability in testing capacity. One of the physicians interviewed mentioned lack of personal protective equipment as a reason why primary care practices aren’t taking on testing.

Many of the staffers at my practice gave up on having full PPE long ago and aren’t gowning up when performing swabs. Although we have an adequate but not ample supply, it’s a pain getting gowned up, and most of our staff members are taking their chances. Those of us who aren’t actually performing the swabs aren’t allocated gowns, so you just get in the habit of figuring you’re exposed and sprint to the shower when you finally arrive home.

CMS continues to blast out information like nothing else is going on in the world. This time it was an update that “2021 MIPS Self-Nomination Materials” are apparently are now available, so Qualified Clinical Data Registries and Qualified Registries can now start the paperwork for next year. I feel like I’m a million miles away from MIPS right now, and I’m betting 80% of the US healthcare folks share the sentiment.

The FCC continues to fund telehealth projects as more organizations enter the space. I have practiced on several of the major telehealth platforms, and all I can say is that they have a long way to go before they have the features that physicians really need to do a good job. My experience is that they’re clinging to their episodic care roots and there’s not much funding to create the kind of longitudinal health record that is needed for coordinated care.

None of the systems I’ve worked in have the ability to receive records from patients or providers (or at least I’ve never been trained on how or where to see them), so it’s like starting with a new patient every single time. They are also light on clinical decision support. Documentation is barely a step above Microsoft Word, with many providers keeping their own cheat sheets for copying and pasting.

A recent report from McKinsey & Company looks at the potential for a $250 billion shift to telehealth in upcoming months and years. That’s approximately one-fifth of what payers spend on ambulatory and home health visits. I’m not sure I’m quite that optimistic given the fact that in the month since the report was released, many patients are going back to brick-and-mortar visits. Since we didn’t ramp up remote provision of other services like blood draws for chronic condition monitoring, it’s often just as easy for a patient to go back to their physician’s office for labs and a visit than it is for them to do a telehealth visit and then have to go to a reference lab’s patient service center. In order for a seismic shift to occur, we have to figure out how to deliver other outpatient services remotely and how to practice telehealth in non-crisis situations.

Other care delivery paradigms such as Direct Primary Care (DPC) are also gaining traction. I was interested to see that Baylor Scott & White is including DPC as part of its health plan. Employers can choose to separate primary care from other fee-for-service offerings. There are a lot of different flavors of DPC out there, and in this one, the physician is paid a flat rate for all primary care services regardless of the number or type of visits. It’s much more like old-school capitation than true Direct Primary Care, which cuts out the middle layer between the patient and their health provider. Another typical hallmark of DPC is that the physician no longer needs software or staff to handle coding and billing processes, which leads to savings. I think the Baylor approach is going to lead to practices not realizing the benefits because they’re going to have one foot in the boat while the other is still on the dock.

From LegalTroubles: “Re: lawsuits from healthcare staff or unions around PPE and related issues. What are your thoughts?” Workers, including physicians, will have little recourse if they suffer illness, injury, or even death from inadequate PPE and unsafe workplace conditions. I’m a member of several COVID-specific provider forums and everyone is singing the same song about lack of PPE and being expected to work at a ridiculous pace in many areas. Any lawsuits will be defended by lawyers claiming that employers were doing what they could in a national health crisis. The reality is that that nearly 90,000 healthcare workers have been sickened by COVID-19, 600 have died, and there’s no end in sight.

I’ve worked in probably close to 100 facilities in my career. Healthcare workers have never had the level of oversight from the Occupational Safety and Health Administration that you see on most construction job sites. When is the last time you saw a “days since last accident” poster in the patient care areas of your hospital? Personally, I never have, except once on the loading dock of big-city tertiary care center.

The other day I refused to provide care to a thrashing patient due to the risk of a needle stick injury. I had to wonder whether I would be backed up by administration.

Even if employers operated with the level of diligence that they should, playing the “sorry, we just can’t get supplies” card is our new reality. The abject failure of this nation to fully leverage the Defense Production Act or other legislative actions or incentive programs to provide healthcare workers with the protective equipment they need (and deserve) is despicable. The reality is that each and every one of us, more so than the general population, wakes up each morning waiting for the other shoe to drop and wondering whether every cough or sniffle is the beginning of the end.

Do we have any MD/JD or DO/JD or legal folks in the room? What’s your take on the reader question? Leave a comment or email me.

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