The past month has seen unprecedented change sweep across individuals and businesses throughout the country, including healthcare providers. The COVID-19 pandemic has left physicians and medical practices reeling and trying to balance livelihood with safety and appropriate use of resources. As small business owners, many large-group practices are having to now tackle complicated issues related to labor force, supply chain, and keeping their patients and providers safe during the pandemic. Most of the discussion of physician practices during the first several weeks of the crisis regarded urology under the umbrella of the “critical industry” of healthcare. This would seem to encourage a “business-as-usual” approach in order to keep patients out of the hospital and their primary care physician offices, which conceivably were being inundated with COVID-19 preparation and patients. The CDC and state recommendations were primarily focused on what hospitals should be doing, and centered around restricting elective surgeries. For urologists, that meant very few obligate reasons to perform hospital-based procedures (obstructing stones, high-risk renal/urothelial cancers, acute bleeding, etc).
As the situation has worsened and nonessential happenings around the country are increasingly shutting down, we are all taking a hard look at our practices and critically evaluating the urgency and necessity of our work. Various regulatory bodies have weighed in on all aspects of medical appropriateness and resource preservation. Based on this, large urology groups appear to taking the same approach:
Restricting all office and ASC procedures to those considered emergent or essential. This means only active pain, bleeding, or cancer progression should be operatively managed. Roughly this comprises about 10% to 15% of typical volume.
Restricting person-to-person office visits; only patients with urgent issues or receiving active cancer treatments are allowed to be seen.
Identifying and supporting critical services that need to continue for our patients well-being. For many large groups, this includes in-office dispensing of cancer drugs and continuation of radiation services for patients on therapy. Cancer infusions have been continued but newly started only in selected cases, similar to how medical oncologists are currently operating.
Practices heavily involved in research have questioned the utility of maintaining research staff and visits during the pandemic. The FDA has issued guidance on clinical trial proceedings during this time, and many cancer trials are encouraged to continue at the sponsor’s discretion.
Even for these “essential” services, groups are adjusting down operations to allow for maximal intervals between patients and to minimize the number of visits required. Office and clinic staff have been curtailed. There has been some discussion about completely shutting down ASCs during this time, mainly to preserve personal protective equipment. We feel the ASCs represents an important site of service where patients can get urgent procedures done quickly and with minimal healthcare worker contact. These procedures (catheters, stents, fulgurations, etc) would otherwise need to be done in a hospital setting. Both providers and patients benefit from keeping our patients at the current time out of large medical facilities, which likely represent local epicenters of COVID-19 infections.
The most substantive change in urologic practice has been the emergence of telehealth services. Many groups and institutions have had preliminary experience with telehealth platforms and even participated in pilot programs. However, previous CMS limitations on eligibility and reimbursement for these services kept them out of mainstream practice. With recent urgent passage of the CARES Act, those limitations are now gone and any Medicare-approved provider (including APPs) can now bill and collect on a scale equivalent to in-person visits. Outpatient visits involving both new and established patients can be done easily with a video/audio platform over a phone, computer, or iPad. Early telemedicine experiences in our large groups have been very positive, and patients have been thrilled to be able to communicate to doctors (even about their nonurgent conditions) during this time. There are certainly still some kinks to be worked out, but it appears that telemedicine will be one of the few positives to emerge from this experience and will likely occupy a large role going forward in outpatient practice. It is likely that CMS will reevaluate the “rules” for telemedicine billing once the crisis is over; but, given initial successes, it is unlikely to be changed dramatically. Infrastructure for these visits will likely need to be expanded and supported by all groups looking to stay current in the marketplace. Furthermore, the addition of local/regional facilities for urine drop-offs, blood draw kiosks, and so forth will be necessary to accommodate patients’ increasing demand for remote services.
The stark reality is that most urology groups will have approximately 70% to 80% of their typical work postponed or cancelled during this time. Traditional business models and revenue cycles are completely turned upside down for most of us. High capital outlays (large buy-and-bill medications or services, new equipment, new hires) all could be very limited in the months to come. We are seeing many industry sponsors and healthcare companies provide services with discounted and delayed costs. As most of our groups carry 50+ employees, difficult decisions regarding workforce and day-to-day operations have become necessary. Some have chosen to furlough employees; others reduce hours while keeping them on payroll. A few smaller groups have been forced to let go of their employees permanently. We have all had to look into federal unemployment policies and local emergency fund availability for our workers. New government stimulus funds may be helpful in allowing practices to keep a substantial number of employees thus making “the road back” less challenging in a few months. Our groups have consolidated our offices and ASCs as much as possible to provide lean and efficient services for those who need it the most. In many groups, physicians and administrators have agreed to dramatic cuts in salaries, setting a healthy tone for all other financial cuts that need to be made. That being said, there is power and stability in numbers, and many large groups have the resources and leadership to be reliable providers of necessary urologic services during this time. Keeping patients and employees safe and cared for during this time has become our primary goal and something that we can still strive to do well.