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Private Practice / COVID19: Financial vs. Moral Obligation to Close Office

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  • Private Practice / COVID19: Financial vs. Moral Obligation to Close Office

    I'm sure many private-practice docs are in a similar position, so I'm looking to hear about current (and evolving) protocols in place regarding balancing our moral obligation to reduce the spread of COVID19 against our ethical/financial responsibility to our practice, employees, and patients to provide care.

    Personally, we are in a 2-person orthopedic hand surgery practice in California. We provide a valuable to service to our patients of course, but let's be honest - we're not saving lives on a daily basis. We save wrists, and fingers, and reduce pain. However, continuing to see 40-60 patients per day, many of whom are elderly and with comorbidities, may very well be putting their lives at risk.

    At the same time - we have to keep our business running. We have 18 employees and we're not helping out anyone if we have to lay off our staff, many of whom are single mothers without any financial reserves. All of our surgeries are performed at ASCs, and currently there are no plans to close (and from what I hear coming out of Washington state, despite hospitals stopping elective procedures the ASCs are still performing cases).

    I'm sure there are many other private practice docs who are struggling with the same decision. Please share your though process. Some topics/options to consider:

    - Reduce hours and reduce patient exposure by limiting to only emergent/urgent cases?
    - Limit patient visits to only low-risk patients (under 60 years old, no co-morbidities)?
    - Offer all patients the opportunity to reschedule, but continue to see anyone who wishes to be seen?
    - Continue all surgeries vs. only perform emergency surgeries (unclear whether surgery has a higher overall exposure risk vs. lower risk than office visits)?

    Since we are private practice we are unlikely to be "told" what to do by anyone unless the government mandates a stop to all elective medical care - which seems very unlikely. So at the end of the day it's up to us to make a decision that is socially responsible, financially responsible, and allows us to sleep at night.

  • #2
    I'm a non urgent, non primary/family care doctor in private practice. I get a decent amount of semi-emergencies (minor trauma/injuries, infections).

    I have been enduring many of the same thought processes, (& struggles at times). For now I am seeing anyone who wants to come in. My area has not been "hit" yet, but my state is rapidly finding positive people, & 2 of the 4 bordering towns have confirmed cases.

    I've been personally "extra cleaning" the rooms & surfaces. My smaller amount of staff would also not like to be without pay. Maybe the federal "relief" package will give them paid sick time. But if I or my staff aren't actually sick...

    When my staff is confirming appointments over the phone, we are mentioning to use caution if coming in. If any illness or worry, reschedule as needed/desired. Patients have replied either:

    1) "I'm not worried Doc."
    2) "I wasn't going to reschedule, I'm/he/she (is) in too much pain to wait any longer to see you."

    On my end, we are not trimming/moving appointments. Yet at least. If I worry about exposing other patients / my staff / myself, or am ordered to, I will trim the schedule; that's the plan right now.

    The several outside facilities I attend (senior living facilities & nursing homes), I will be contacting them if they want me to continue my weekly sessions or not. Yesterday a nurse from one facility confirmed that I was going there Monday for 2 new patients with minor injuries each. I will call her again Monday morning...
    "Oh look another bajillion point declin-Ooooh!!! A coupon for pizza!!!!" <--- This is what everyone's IPS should be. ✓✓✓

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    • #3
      Sorry, because I’m sure this is useless to you. It’s a tough question. But as a psychiatrist in private practice, I’m working remotely from home. I do feel that since I am able to do this, it would be unwise to subject myself and my patients to the risks of traveling to and from my office.
      My Youtube channel: https://www.youtube.com/channel/UCFF...MwBiAAKd5N8qPg

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      • #4
        You also need to think about liability.
        ​​​​What if you test positive, and then your patients start popping positive?

        Maybe halve the appointments, spread out the patients so many fewer in the waiting room, only do truly urgent cases? Maybe bar medically co morbid, those over 60?

        Rather than laying off staff, use some free up hours and pay them to thoroughly clean and sanitized and so forth?

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        • #5
          Cash flow management is key. Not something you’ll see right away but in another month or so depending on your A/R cycle. Take actions now to address this.

          Expect and even encourage reduced volumes. Pre-screen people with phone calls and reminder texts, have signs on the door turning people away if they have had fever/cough, have patients wash their hands on entry, screen all personnel at the beginning of the day, wear protective gear. I’ve started wearing a N95 mask and change gloves more frequently in each visit. I’ll start wearing eye protection as well.

          I wouldn’t shut things down, but think long term here. As residual owners of profits you’re the ones who will take the hit, because if you don’t now you’ll lose employees and deal with ramp up issues in a matter of months. Let this be a lesson to those operating with high fixed costs. In revenue down times you get hit the hardest.

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          • #6
            Also, plan on your staff needing to attend to their children. It’s only a matter of time, but all schools will close. Anticipate this. Have plans in place now to address that from an operational perspective, first by understanding who would be affected. Then develop a plan if you haven’t already about how you’d pay that individual.

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            • #7
              Do you have overhead insurance? Since I was in solo practice I had this. I used it when my city was hit by a tornado and had no power for a week.
              I would have patients use their cars for a waiting room. Give everyone the option to reschedule. Increase your working capital. Start thinking about cash flow now!! I missed a week of office once for a malpractice trial and you need to think about this prior. If this gets really bad like Italy I think the ASCs will not be doing elective cases.

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              • #8
                Our hospital has business disruption insurance, similar to what Hatton is describing. Any overtime, extra work from non-exempt employee, loss of revenue, can be captured by this insurance. Do you have a policy like this?

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                • #9
                  thank you for posting this we are undergoing something similar as an outpatient private practice

                  we are linked to a hospital and hospital admin has told us to keep working like nothing is happening

                  the average age of my patients is >70 so i also worry about bringing a bunch of them into a waiting room

                  hospital admin has instructed us to ask screening questions (which are woefully outdated and don’t work as people lie)

                  im planning on having our front staff take a temperature on everyone before they are brought back to the clinical area

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                  • #10
                    This is an excellent question and thoughtful replies so far. I am in a similar situation and we haven't come up with a good plan. I'm hoping that things will just slow down a bit (which would simply decrease my personal income temporarily) as opposed to come to a complete halt (which would stop all revenue and affect staff pay, etc). If the latter happens, what is you plan? How about the ASC? Tell hourly staff "sorry, you're out of luck, we're not paying you if the office is closed and you're not working, feel free to call the federal government on whatever relief bill they pass" ?

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                    • #11
                      On the "to do" surgery side of things- hospitals in hard hit areas are starting to cancel elective cases, partly because of the anticipated need for beds/vents, and the increased exposure to staff (which turns into a quarantine of half your staff). And well, you dont want to be the hospital that sends a covid pt or pt exposed to it by staff to a nursing home unknowningly. For ascs/day surgery a little less of a risk but- some pts will cough on emergence no matter how good an anesthesiologist is. They will spread their germs around your asc operating room. If one of them tests positive a few days later for COVID, what's the contigency plan? Will your staff take the increased turnover time to clean everything thoroughly between pts even if no one is symptomatic? Some ascs do great jobs, unfortunately some staff are so afraid of having a longer turnover time that they cut corners. I dont think there's a right or wrong answer, until someone tests positive in your facility. Then I think the smart thing would be to just reschedule everything for 2 weeks and do a thorough cleaning.

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                      • #12
                        Originally posted by abds View Post
                        This is an excellent question and thoughtful replies so far. I am in a similar situation and we haven't come up with a good plan. I'm hoping that things will just slow down a bit (which would simply decrease my personal income temporarily) as opposed to come to a complete halt (which would stop all revenue and affect staff pay, etc). If the latter happens, what is you plan? How about the ASC? Tell hourly staff "sorry, you're out of luck, we're not paying you if the office is closed and you're not working, feel free to call the federal government on whatever relief bill they pass" ?
                        from a staff morale standpoint, if you (rich doctor owners in their minds) can afford to pay the staff for 2 weeks without them working, they will be loyal to you forever. If you dont and go the "sorry youre out of luck" route, expect them to start looking for other jobs. Also expect them not to self quarantine until really sick if they come in contact with any covid people. Their fear of financial risk will be too much. this will cause the disease to spread even quicker. Some states are considering bills to help businesses with losses stemming from this. Are there insurances for this as asc business owners?

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                        • #13
                          Some really excellent ideas here, maybe they can be consolidated and stickied?

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                          • #14
                            1. For the post above about liability that is why no way would I get tested right now. If symptomatic I would just stay home . Otherwise you’ll be treated like you have the bubonic plague. Patients will get exposure letters, staff/pts will be upset, etc.

                            2. Our clinic attached to our hospital is still going full steam ahead. Admin even had the audacity to rebuke docs who cut back clinic saying “our patients still need our service and availability.” Elective procedures still going.

                            3. I agree that most docs shouldn’t have a bunch of 70-80s hanging out in a big waiting room with seeing a doc when it could wait.. but it is tricky.

                            ultimately I figure I’ll make up what I lose outpt for what I’ll make inpt (not withstanding missed time to sickness/quarantine)

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                            • #15
                              EastBayHand
                              ”We provide a valuable to service to our patients of course, but let's be honest - we're not saving lives on a daily basis. We save wrists, and fingers, and reduce pain. However, continuing to see 40-60 patients per day, many of whom are elderly and with comorbidities, may very well be putting their lives at risk.”

                              This brings up not only ethical decisions, but the guidance, wording, responsibilities to your patient, various degrees of urgency.

                              ”non-essential” and “elective” do not translate into anything other than a life threatening situation.

                              •In the absence of pain and a service needed to prevent an increase in harm, don’t do it. If a surgery can solve the problem in three months, absolutely no reason to do it next week.

                              •If a condition will deteriorate or cause significant disruption in the patient’s life, you have a higher obligation to treat the patient. Withholding care is causing damage. Yes that means, do no harm.

                              Basically it may come down to a trauma type event vs an existing condition. If you made decisions based only upon medical need vs want, you would probably find it easier. Saving a wrist or finger or preventing pain is valuable. Can it wait is your medical decision. It is a yes or no decision.

                              Some patients will get pissed for denial of service and your revenues will take a dive. Those are business decisions, not medical about life saving.

                              Can it be done just as well later? Your first duty is to the patient. Every one of your staff is better off medically not working. That’s business too.

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