Physicians in metro Detroit are recalling hundreds of furloughed staff, reopening shuttered offices, ordering deep cleaning, scheduling delayed appointments and hoping the expected fall surge of COVID-19 cases is mild and doesn't lead to another partial shutdown.
Dr. David Mayo, an orthopedic surgeon with Michigan Orthopaedic Surgeons PLLC in Southfield, said the 30-surgeon practice is moving to fully reopen its six offices. He said the practice, which is down about 16% of normal volume — including telemedicine — will increase in-office visits as patients feel more comfortable scheduling appointments.
Dr. Paul Ehrmann, medical director for the Family Health Care Center in Royal Oak, said his two-physician practice was closed from March 23 to May 10 but still connecting with patients through telemedicine. The past month he has seen an increasing number of patients and is bringing back the seven staff members who were furloughed.
John Micallef, CEO with Oakland-Macomb Obstetrics & Gynecology PC in Rochester, said deliveries didn't slow for expectant mothers, but prenatal, well-baby visits and ultrasound tests declined substantially. He said many patients were nervous about coming in and switched to telemedicine when they could.
Dr. Steven Grant, a Bingham Farms internist, said several patients who came into his office recently with high blood pressure and diabetes symptoms couldn't have been diagnosed properly by telemedicine because they needed blood work and other tests. He suspects those patients would have ultimately wound up in a hospital ED.
Ewa Matuszewski, CEO of Rochester-based MedNetOne, said many of her 900 physician members have experienced heavy financial hits because of the partial shutdown. Last week, the physician organization released a 20-page COVID-19 return to practice playbook and 12-minute video to help physicians safely reopen.
Dr. Anthony Ognjan, an infectious disease specialist who also practices at an HIV clinic in Sterling Heights, said the vast majority of his time was spent at hospitals managing critical care patients at McLaren Macomb Hospital. His 200 HIV patients remained stable as some of his partners helped to take care of them.
But Ognjan said he saw many patients come into hospitals in poor condition because they could not or would not see their primary care doctors.
"During the pandemic a lot of primary care offices were closed and people had no place to go," said Ognjan, who is employed by Chicago-based Metro Infectious Disease Consultants. "We saw some pretty serious infections and heart conditions with people who had put off coming to the hospital. I have a guy in the ICU right now. He has a huge liver abscess. This thing didn't develop overnight. He was just afraid of going to see his physician."
Ognjan said he has seen people in the hospital with secondary complications after heart attacks who develop pneumonias. "I've seen people with genital problems, people with kidney stones, infections, and urine retention issues because they didn't see their urologist or primary care doctor," he said.
Physician practices ramp up
The COVID-19 pandemic — hitting hard in Michigan with more than 5,600 deaths and 58,000 positive cases as of late last week — has pushed the healthcare delivery system to the max. It overwhelmed many advanced-care hospitals in metro Detroit and shut down many physician practices to emergency or urgent care-only services.
More than half of all physicians work in practices with 10 or fewer physicians. Most of those small practices have little financial backing to weather long-term downturns.
While none of the practices Crain's interviewed said they are in danger of closing, most said patient volume dropped 50% to 70%. Even with some federal financial aid, several doctors said cash flow slowdowns are starting to hit now and will build over the next month as health insurance reimbursements begin to slow.
Matuszewski said MedNetOne financially supported some practices with small loans and provided large amounts of personal protective equipment when needed.
"We have employed doctors who work in practices who were laid off. They used to be independent practitioners," she said. "They have bills, mortgages and were challenged. We helped them fill out forms for advanced Medicare funding and payroll protection program applications."
But Matuszewski estimated the financial hit for practices will range from 10 percent to 15 percent when revenue declines and expense increases are factored in.
"The initial investment (with reopening) will be significant, especially if they need to purchase plexiglass shields for the waiting room and front desks," she said. "A 30-day supply of PPE and cleaning supplies aren't cheap either. Many small practices aren't used to having these expenses."
Many doctors and practices turned to telemedicine to make up lost revenue from in-office visits. They also use telemedicine to connect with their patients and try keep conditions from worsening.
"Looking forward I would anticipate a 20% drop in patients coming into the office, but we will continue to do telehealth. That is here to stay," Ehrmann said.
For Mayo, he didn't have to look further than his own office staff for real-life examples of why wearing personal protective equipment is important.
"We had a midlevel employee who became sick very early on and ended up in the hospital," said Mayo, who said no other employee got COVID-19. "She was on a ventilator five days and is still in the hospital recovering. It was a very dramatic and profound experience for all of us to realize this can happen. ... We made some changes to slow down our business and everybody was on board."
Under Michigan's emergency orders that restricted nonessential and elective care appointments for two months, physicians warned that delaying preventive care visits or postponing care for some people with chronic diseases could lead to more serious medical problems.
Over the next several months, community-based primary care physicians say they will ramp up efforts to conduct physical exams and will be the frontline treaters and testers for coronavirus. They say they will help prevent single cases from turning into outbreaks and work to relieve the strain on hospitals and nursing homes.
"We're always concerned about a (second COVID-19) surge and a concern about the flu season this fall," Ehrmann said. "It's up to the primary care physician to keep our patients safe. We need to keep a close eye on all the preventative and chronic care needs that patients have."
Monitoring COVID-19 symptoms will also be a major responsibility for primary care doctors, he said.
"We want to prioritize people getting those physicals over the next three or four months," Ehrmann said. "We know our patients who are at a higher risk with chronic diseases and we need to do preventive screening on other. We don't want to allow things to fall by the wayside and have something end up being urgent."
Grant, an internist for 40 years and chairman of the Greater Detroit Area Health Council, said his Bingham Farms office shut down for six weeks and in reopened in mid-May. He said staff precautions include everyone wearing masks and spacing appointments every 30 minutes instead of the typical 15 minutes.
"We did a lot of telemedicine and phone calls to refill medications and take care of whatever problems we could," Grant said. "We haven't been real busy because a lot of people are afraid and still don't want to come to the doctor's office."
In 2017, Michigan Orthopaedic Surgeons merged five separate practices and now has more than 40 providers with 250 employees at six locations, including Beverly Hills, Bingham Farms, Royal Oak, Southfield, Troy and West Bloomfield.
But once COVID-19 cases broke in mid-March, orthopedic surgeon Dr. Rachel Rohde said the group was forced to close its West Bloomfield office and the other offices immediately went to a necessary appointments-only status.
"Patients who needed urgent orthopedic care for fractures, infections, severe pain who were in the middle of recovering from surgery or other significant injury obviously still needed care, so they were seen by a skeleton crew in the office," she said.
Rohde said MOS has taken all necessary precautions to prevent spread of COVID-19.
"Patients, staff, and physicians all wear masks. Everyone is screened upon entry. Social distancing is required and visitors are limited," she said. "Rooms are sanitized between patient visits. These few weeks of getting our feet wet have prepared us to accommodate the patients we know have been eager to have their non-life-threatening orthopedic issues addressed."
Dr. Zachary Vaupel, an orthopedic surgeon who also is with Michigan Orthopaedic, said he hopes people who have delayed evaluations for pain or other problems come in because the offices have been made safer. Most surgeons are still conducting 50% of patient visits through telemedicine.
During the worst of the COVID-19 outbreak, Vaupel said surgeons moved many cases to UnaSource Surgery Center LLC, the practice's joint venture facility in Troy.
"It was a blessing to have UnaSource. We had no COVID-19 patients there and were able to take care of many people," said Vaupel, adding that he continued to take calls for fractures at Beaumont Health hospitals in Troy and Royal Oak. "It was different to have our entire orthopedic unit turned into a COVID-19 unit" in Royal Oak.
Mayo, who is chair of the finance committee with Michigan Orthopaedic, said the surgery practice was down about 70% in March and April, but patient volume varies by specialties.
"The last three office days I've had what seems like a normal number of patients who need joint replacements, but they're all saying that they want to wait till October or November or maybe even next year," said Mayo, who specializes in joint reconstruction and replacement surgery. "My office volume is increasing, those patients are not not really ready for surgery."
Mayo said surgery for arthritis or other pain issues is mostly elective. "People seem to be willing to use their cane for a while longer rather than just jump right into surgery," he said. "The fractures and pediatric cases will be back to full volume. The rest of it will not be."
To improve efficiencies, Mayo said the practice changed some staff job descriptions. One change gave medical assistants additional cleaning duties.
"Previously they would change the sheet on the exam table. Now each medical assistant goes through and wipes off the countertop, the chairs, the armrests, the door handles and the light switch by hand," Mayo said. "Twice a day all the countertops are wiped down at the front desk, the checkout desk, the waiting room, and then the workstations for the nurses and the physicians."
Mayo doesn't believe expenses for equipment and cleaning will increase that much.
"Everyone who sees patients are wearing masks, disposable gowns and gloves, but the cost of disinfecting won't be that much because we do that type of cleaning already," he said. "We've asked our cleaning service to do some additional work, using isopropyl alcohol or peroxide and disinfectants on the countertops in the workstations in an exam room."
But personnel costs will increase because the practice hired an additional 7.5 full-time equivalent employees to screen patients at the clinics' front doors and hand out masks to patients who don't have ones.
Oakland Macomb OB-GYN
As one of the largest obstetric and gynecology practices in Michigan with 17 physicians and midwives and 100 employees, Micallef said the practice closed its Troy office in March and consolidated operations in Rochester.
"We didn't have any furloughs and we were able to get our telemedicine program up and running from day one," Micallef said. "Our patient load was down overall and we had to stop gynecology, but we converted a lot of patients to telehealth."
Micallef said Oakland Macomb planned on ramping up its telemedicine program this year, but the COVID-19 crisis sped up implementation.
"It's been a huge success and added to the lessening of anxiety for our patients knowing that they could actually see and speak to their provider," he said.
Last week, Micallef said the Troy office was reopened after complete disinfectant cleaning and reorganizing the office for social distancing with signage and floor markings.
"We trained employees to be more aware of things we took for granted," he said. "We started up the gynecology side and making sure patients are spread out."
Micallef said patients were screened at the door with a checklists of asks such as temperature checks. "If they have symptoms, we ask them to come back later," he said.
Looking ahead, Micallef said the practice expects a second surge of coronavirus will hit in the fall about the same time as flu season.
"We believe it will die down in the summer and are preparing for the upcoming fall. We are collecting personal protective equipment, lots of supplies. We don't want to be surprised again," he said.
Micallef said Oakland Macomb took a large financial hit due to the loss of in-office visits and surgeries it was unable to complete.
"We are hoping that the financial hit will be more of a delay that can be recouped with proper scheduling at a later date," he said.
Financial impact, support
Physician practices received some financial support from two federal Small Business Administration loan programs — the Paycheck Protection Program and Economic Injury Disaster Loans — but both were difficult to access and took a long time to receive, doctors said.
Like many practices, Rohde said the economic impact to Michigan Orthopaedic has been significant.
"We were able to obtain grant funding as well as participate in the PPP that has helped us reestablish our staffing levels appropriately," she said. "The true financial burden of this will be realized in the next few months, as the insurance reimbursement lags, but we feel very fortunate to have been able to manage this period of crisis."
Mayo said MOS surgeons gave up all compensation for six weeks through April. The practice's senior executive team also took 50% pay cuts.
"All employees we kept the first few weeks took a decrease in their pay," he said. "Our commitment to them was that this would be temporary and that we would make them whole eventually, but everybody was willing to make sacrifices so that we would be able to continue to pay for people who were working."
"As physician offices reopen with changes, patient visits ramp up" originally appeared in Crain's Detroit Business.