EPtalk by Dr. Jayne 12/10/20

As COVID-19 ravages large swaths of the US, CMS continues to push a strategy to enhance hospital capacity that is somewhat slow to start. It allows ambulatory surgery centers to provide inpatient care when needed. However, the problem is that most clinical staff at ambulatory surgery centers aren’t used to ongoing management of very sick patients. Just because there are more beds doesn’t mean there are more people to staff them. Our area has a surplus of beds but limited staff, which makes for some interesting spinning of hospital capacity rates.

The strategy also allows certain patients who would normally be admitted to the hospital to be cared for in their homes. Although many academic centers are gearing up programs to make this a reality with high-quality coordinated care following the CMS guidelines, some organizations are forcing greater at-home care by just discharging patients as early as possible even though they may not meet conventional discharge criteria. It will be interesting to see how this impacts readmission rates down the road. Analytics gurus, start your engines.

With all the clinical shifts I worked in November, I missed out on a telehealth-related bill introduced in Congress that would penalize states that aren’t part of the Interstate Medical Licensure Compact. I’m fully supportive of anything that makes it easier for us to practice across state lines. I live fairly close to a state border and can have a telehealth visit with some patients while they are at work in my state, but it becomes illegal if they start their visit from their home across the river. HR 8723 would give states three years to join the Compact or risk not receiving funding from the Bureau of Health Workforce, which rolls up under the Department of Health and Human Services. State licensing boards would also be blocked from some federal grants if they don’t have a “public awareness campaign to encourage specialty physicians to practice telemedicine.”

The Interstate Medical Licensure Compact was launched in 2017 by the Federation of State Medical Boards and now has its own governing board. Its goal is to create a more streamlined process for physicians to gain licensure in other states. Currently 25 states plus Guam are live with five more states scattered throughout the process.

When I started practicing telehealth, my mentor encouraged me to apply for multiple state licenses. I quickly found the process to be arduous and expensive just for the applications, with some states requiring bizarre documentation such as high school transcripts that are largely irrelevant to the competency of a physician who has been in practice longer than some high schoolers have been alive. Once the licenses are approved, there is then annual maintenance of those licenses, and the risk/benefit equation quickly tipped to the former.

I’m deep in the final stages of a product launch this week, and this is the first one I’ve done in a totally remote environment. I’m used to working in a command center with everyone under one roof for rapid troubleshooting and hotfixes, which just isn’t realistic given the current pandemic conditions. Nearly all the resources are working from home, which has created some interesting situations, including a toddler attending one of our final checkpoint calls. The organization is doing a great job trying to foster togetherness and support the team during this high-stress situation, including sending gift cards for take-out and delivery meals.

Although I miss the feeling of togetherness and the satisfaction of working as a team, it’s just one more element of the new normal that many of us will be working in for the foreseeable future. I’m also glad for some time away from patient care so that I can refresh and recharge. Of all the go-lives I’ve supported, no one has ever tried to get me to look at a Ziploc bag full of their stool sample, which happened to me three times during my last few days of patient care.

Nearly 100% of the chatter in the virtual physician lounge this week surrounds whether the Pfizer COVID vaccine will be approved on Thursday and how quickly organizations can start administering it. The lack of a national vaccine strategy has created vast disparities across states with regards to how it will be administered to frontline healthcare workers. Over the last couple of weeks, our area’s major health systems have announced their plans for employee vaccination and public health organizations have started to talk about their plans for vaccinating high-risk patient populations. However, it didn’t seem like there was any plan for vaccinating frontline healthcare workers at non-hospital entities.

After getting an unsatisfactory update from my employer, I felt like I was on my own and connected with a group of independent physicians who are in the same situation. They’ve been making phone calls to various county and state agencies along with hospitals and health systems for weeks, and each entity seems to point fingers at someone else who “should have been responsible” for including us in the planning. Just talking to the physicians in the group, our respective organizations deliver over 500,000 patient visits each year and represent close to 3,000 COVID tests each day. It doesn’t begin to reflect the amount of care delivered by independent physicians across our city, let alone the state.

My contribution to the effort has been reaching out to state and local professional societies and elected officials. Although many of the individuals we have collectively contacted are sympathetic, none of them are willing or able to take the burden from us and carry it forward. This has been such a long, hard slog and the emotional impact of knowing that physicians who don’t even care for known COVID positive patients will be vaccinated but we won’t, just because of who we work for, is enough to push us over the edge.

The best comment of the day came from the physician advocacy rep at my state professional academy: “It is truly unfortunate that something so important is so difficult to achieve.” It’s not like we haven’t had months to plan this, or in the worst-case scenario, could have just copied from the “smart kid” state next to us that seems to have a fully formed plan.

How is your state or community handling vaccines for non-hospital frontline healthcare workers? Leave a comment or email me.

Email Dr. Jayne.