On Tuesday, November 17, during the first day of the two-day APG Colloquium 2020, being held virtually and sponsored by the Los Angeles-based America’s Physicians Groups (APG), which represents physician groups involved in value-based contracting, the first panel discussion of the day focused on the impacts that the COVID-19 pandemic has had on medical groups nationwide.
Don Crane, APG’s president and CEO, led a discussion session entitled “Organized Physician Groups: Adaptations to COVID-19.” His panel consisted of Clive Fields, M.D., co-founder and CMO of VillageMD, a Chicago-based care management organization; Stacey Hrountas, CEO of the Sharp Rees-Stealy Medical Group (San Diego); Mark Mantei, CEO of The Vancouver Clinic (Vancouver, Washington); and Kelly Robison, CEO of the Brown & Toland Physicians (San Francisco).
Crane began by asking his panelists, “Are you the same group you were before COVID-19?”
“Seventy percent of our revenue is prepaid, “Sharp Rees-Stealy’s Hrountas said, “and, hallelujah, because it saved us during COVID! I would say we’re not the same. We’ve really honed in on our reliance on technology an data,” she emphasized. We were up to 75 percent telehealth at the height of COVID. We stood up our virtual urgent care over a weekend, because we had to, to take care of our patients. Our stringent attention to infection prevention. We really leaned into that. The level of cleaning in our front and back offices is highly enhanced. Greeters and screeners: in the future, if this happens again, we won’t just have hand sanitizer and masks available, we’ll make sure to require masking on entry. And the last thing is really our people and culture; we were in the middle of an alignment around a service line model, when COVID hit. So we quickly came together to quickly resolve issues on the front lines, and that will continue.”
“We’ve all had similar experiences in terms of the acceleration in technology,” VillageMD’s Fields said. “We’re all impressed by some of the regulatory relief that’s come out of the government, faster than anybody would have imagined. Our group is composed of smaller groups of entrepreneurial physicians; and we’ve seen something of an unleashing of that entrepreneurial spirit. I think that primary care as a specialty really rose to the challenge, and there’s a certain amount of pride in the plasticity and the responsiveness to patients. We’ve all seen the horrors of this virus, but it’s important to remember that 98 percent of patients with the virus are taken care of at home. And we’ve really delivered on the promise of primary care, that we can really deliver proactively as well as reactively. I think the big change for the long haul will be the cultural change, and the unleashing of that can-do attitude.”
“I would say we’ve had a combination of the experiences of Stacy’s and Clive’s,” Brown & Toland’s Robison said. “We have 2,700 physicians throughout Northern California. We’re mostly different now,” she stated. “We have to look at the corporate IPA structure on the management side; our clinical physicians whose practices we own and manage; and this broad network of physicians who own their own practices. So how we’ve had to adapt has been very important. We’ve embraced technology, including telehealth, and have had to help physicians in that network setting. We’ve also had our own transition going on. We were in the midst of a system upgrade, and went live on the first wave of our new EHR during COVID. And we were able to embed additional home services and technological services. So, trying to balance the changes to infrastructure happened at the same time. So it’s been an interesting situation.”
One panelist noted the contrast between now and then. “We’re a lot different now,” said The Vancouver Clinic’s Mantei. “And a lot of people talk about returning to normal; we’ve adopted a philosophy that we want to return to better. I keep a little chart, and I call it my silver linings chart, of things we’ve really accelerated as a result of the pandemic,” he reported. “And we’ve opened two new sites, recruited 49 additional clinicians, and it became very evident to all the shareholders and clinicians that what really saved us financially was bonuses from the health plans, and the eventual move to full risk. The other fascinating thing has been the expansion of our laboratory. We had always had one, but they’ve really stepped up, and we’re now able to do more than 1,000 COVID tests a day. And we’ve extended occupational therapy to nursing homes, assisted care facilities, businesses that might have developed an outbreak; that’s developed as a separate business line for the group.”
“What were the first days like, when we first heard about the pandemic arriving in the U.S.? How did it feel?” Crane asked his panelists. “What were the first conversations about this like? What was the first reaction?”
“Being a part of a bigger system,” Hrountas said, referencing Sharp HealthCare, “we had that connection, and we had an infectious diseases specialist who had just come back from China. But we quickly realized that we didn’t have adequate PPE [personal protective equipment]; and what do you do if you don’t have enough masks and other equipment? That came fast.”
“Our headquarters are in Oakland, and we could see that cruise ship in the harbor, so it was a very stark reality,” Robison testified. “So I would say that reality hit incredibly fast for us, and we jumped on it. And here we are an IPA, and yet we were the first in the Bay Area to set up drive-through testing, and collaborated with the City of Oakland; and we set up the entire technology for the appointments and tracking. And by March 20, we had started drive-through testing. And because we were the first to test first responders since we were working with Alameda County, they brought the first responders here for care. So I was very proud of our response.”
“We’ve had SARS and Zika and other epidemics,” Crane noted. “Have any of you faced this kind of mobilization before, where you’ve had a similar ohmygosh moment and have had to mobilize and react?”
“The press covered the first few cases here,” Fields noted, “but now we’ve all faced thousands of them. But the move from the anxiety and confusion of March to the order and discipline of April, to the state of things today has been remarkable; but I can’t ever recall the level of anxiety that we felt in March.” In the very first days during which the pandemic began to spread around the country, he added, “The lack of information that fed the anxiety was pretty staggering for an advanced society. But things moved quickly from confusion and anxiety to execution, and what all of our groups are providing now, has been pretty impressive.”
Later on in the discussion, Crane asked his panelists how difficult it was to obtain adequate personal protective equipment.
“The N-95 masks were the most difficult for us to get,” Hrountas testified. “The masks were a real struggle. We had our supply chain guru reaching out to so many places. We did get some from the county, but OSHA said, you can’t use those. So the masking situation was difficult, and that was where some of the fear came, because the CDC, the Health department of California, and CAL-OSHA provided conflicting information. But over time, we were able to develop some consistency. And by December, we’ll have a lot of fitted N-95s.”
Managing care delivery across multiple locations—nuances and complexities
Crane asked his panelists whether they chose to consolidate care sites, as patient volume dipped early on in the pandemic.
“We’ve done that,” Hrountas said. “And we were pretty good in San Diego, but there are about 250,000 Americans living over the border, and they all came back. That did impact us to a great degree. And at the beginning, we consolidated from 22 clinics to 13, to save on PPE, staff, clinicians, as well as security guards. When you take care of populations, not everything can happen through video visits, so we had to start opening it up again. But there’s a whole process you have to go through to open up clinics, and the physicians’ schedules posed a real problem. But doing that was the right thing at the right time, because we had to prepare for the worst.”
“We ended up designating two of our urgent care sites as respiratory care clinics; after two months, we were able to do away with that and reopen them normally,” Mantei reported. “But our area has nearly 200 cases per 100,000, so we’re very worried” about the impact of a renewed outbreak in his area in the near future.
“We maintained our clinics as they were, because we couldn’t ask the nurses to maintain the clinics if the doctors weren’t beside them,” Fields said. “And what came out of that was the incredible teamwork among clinicians and staff. So we have a completely dispersed call center, and I keep thinking of these call center staffers working in their bathrooms because their kids are done with school. We recognize the value of our support staff more than ever. But we have to keep treating everyone for all conditions and situations, of course.”
“Clive, did you formalize the teamwork relationships?” Crane asked Fields. “We’ve always worked in pods of providers, typically, two physicians and two physician assistants, with a team of nurses,” Fields replied. “And though we’d all formalized it on paper, when it had to truly play out that if you’re the only doctor that day and your nurse has to be with you and there has to be someone at the front desk—that kind of camaraderie will have to play on, and it feels good when everyone’s pulling in the same direction.”
“Did any of you do any sort of data analytics, focusing on the subset of the most vulnerable, and do any sort of outreach?” Crane asked.
“We actually developed a COVID fragility index, determining which patients had an 85-percent of mortality if they developed COVID, and reached out to them with equipment and care management, and as far as I know, we have not yet had one of them die of COVID,” Fields said. “We feel really good about taking that data and providing analytics and reaching out to those patients.”
“We haven’t done as much in the analytics area, and we’d like to learn from what you did, Clive,” Mantei said. “But during the downtime of April and May, when a lot of staff and physicians were working from home, we made it a priority to do proactive outreach, whether through phone calls, video visits, whatever. And a lot of education was provided, and mental health got busy and stayed busy, as people coped with all of this. And we’ve really tried to keep our panel sizes low enough so that our doctors really know our patients, and we said, hey, if you can, please reach out to your patients, and that worked out really well.”
“We had our population health nurses reach out to vulnerable patients; and we actually gave some patients gift certificates for food from grocery stores, to keep them safe,” Hrountas reported. “People really appreciated that; we also gave medication vouchers to those who couldn’t afford their medications, as well.”
Telehealth learnings cited
“We’re learning from each other on this call, which is great,” Crane said. “And what is telehealth, and how did you approach it?”
“Because we were in the build space of converting all of our systems,” said Robison, “we went through a very expedited RFP process, and on average, our PCPs were up to that 70-percent range of telehealth visits, and in our employed clinics, we’re still up to about 40 percent, for our employed primary care practices. And now that we’ve just gone live on Epic, we’ve gone live with that telehealth solution as well, so we have two options. And the silver lining is that we got telehealth done.”
“So it sounds as though everyone plunged into telehealth, and now the numbers have dropped somewhat lower,” Crane said. “Where will we end up with the percentage of visits being via telehealth?”
“It definitely varies by specialty,” Hrountas offered. “With pediatrics, there will be more face-to-face visits because of immunizations, etc. Our goal is to keep it at, at least 20 percent. It will depend. The surgical specialties are running around 10 percent. And we really tried to push telehealth with our primary care physicians; everyone kind of got forced to try something now, but now, there’s that silver lining that people are ready for it now. And we’ve developed virtual urgent care; so it did pull some volume from our five urgent care clinics; but it’s a lower-cost setting, and we’re capitated for the most part.”
“Prior to March, I kind of thought of telehealth as ‘1-800, may I have a Z-Pac?’—but it’s evolved forward, and it’s really increasing the impact that our care managers can have,” Fields said. “And looking into the background of a patient can be really helpful. As you look at the patient’s home environment, you can learn things about that patient that can help you with care management. We’re concerned about the maintenance of the waivers for telehealth, but we certainly consider telehealth to be a core component of how we’ll be delivering care.”
“We had always had telehealth as a major thing to accomplish, but we kept putting it off because there was no reimbursement for it, and we’re still 70-percent fee-for-service,” Mantei said. “But within three days, we were able to craft it in a way that we incorporate Zoom into Epic. And it wasn’t perfect, but it sure helped us out considerably. And we’re continuing to run about 8-10 percent televisits, and we’d like to see it reach about 20 percent. Meanwhile, in endocrinology, they’re seeing nearly 60 percent of their visits via telehealth, and it’s pretty impressive.”
Capitated payment—and its advantages in this moment
And, Crane asked, “Tell me about the economics of this, in terms of fee-for-service and capitation.”
“I’m serious, the capitation saved our bacon,” Hrountas said. “What’s interesting is that the visits dropped off faster in PPO, much faster than in HMO, and the telehealth visits have come back much faster in HMO. We’re lucky that Medicare pivoted pretty quickly with the waivers, because that took the financial factors out. It was very confusing with which payers charged co-pays for COVID-related versus non-COVID-related visits, and that’s confusing. And under capitation, who’s going to pay for all these additional lab tests. We’re still having that dialogue with the private health plans. And with regard to Medicare Advantage… On the cap side, you’re worried about the expenses coming in. And we’re trying to make our patients feel safe. But it’s going to be interesting. How long will patients be concerned about coming in for elective procedures? How long will that last?”
“The majority of our revenue comes through capitation, on the MA [Medicare Advantage] and HMO side,” Robison said. “We did see a drop-off on HMO, and which came back faster; PPO is coming back more slowly. And we’re already seeing a decline again in elective surgeries, moving towards the holidays. And the fact that we capitate our primary care providers has been a godsend to them, because it supported their cash flow. We’ve also given supplemental payments to our PCPs, to help bridge the gap, and we’re going to continue to do that again in the next month or so.”
