by John L. Bender, MD, MBA, FAAFP
Featured in the May-June 2020 Colorado Medicine Colorado Medicine.
The COVID-19 pandemic has brought tremendous stress to the practice of medicine in all settings. As a private practice family physician with clinics in Fort Collins and Parker, and a veteran of the Kosovo War, I feel more than ever that physicians are in the trenches with the sheer number of extraordinary challenges and necessary innovation needed to keep our practices open and keep ourselves, staff and families healthy.
We split our Miramont Family Medicine clinics in the north: a “fever clinic” at our Drake office run by my partner Kelly Lowther, MD, and her team, who have taken on the brunt of the testing, and a “well clinic” at our Snow Mesa office. Some sick patients do present at Snow Mesa but we are prepared. Our lobby greeter takes temperatures at the door and anyone sick is either assessed curbside or in special isolation rooms. We feel strongly that we need to meet the demand of people wanting to see their personal physician for medical attention during the state lockdown. We hastily purchased a telehealth license.
PPE and N95 masks
When the COVID-19 pandemic was first diagnosed in Larimer County March 9, I found a 5-year-old N95 mask in my garage from when we built Miramont Family Medicine’s office on Drake Street in Fort Collins in 2015. I have worn it every day since then and, for the week of March 16, shared it with two other medical professionals. I was wearing that mask when I diagnosed three patients who were later confirmed positive for COVID-19.
We almost ran out of masks. That first week one of my employees was able to find 13 masks for 44 people still working in the clinic. Later our church donated more to us, and then one of our four major medical suppliers mercifully sold us another 50 disposable masks. While not as durable, they are better than nothing. With our N95 mask discipline at Miramont, staff sign for a mask and they must make that durable mask last four weeks before they can be issued a new one.
I now have some N95 masks in reserves for the near future for our staff. I suppose I could wear a new N95 mask, but I think I will just continue to trust the N95 mask that I have been wearing that has protected me from COVID at least three times now.
Curbside testing warriors and testing challenges
A recurring theme in news reports for the state of Colorado and the nation is that there are not enough tests or testing capacity to know the full scope of the pandemic and who is infected. Enter Miramont. We did not have access to the free CDC test, but our reference laboratory of 20 years told us early on that they were able to sell us COVID-19 tests for $51 per test. There was just one catch: the laboratory was not willing to actually collect the specimens; they must be collected by a health care provider. And, just as Miramont had donned the N95 masks and PPE without hesitation, our nursing and lab staff began collecting COVID-19 samples on March 13.
Initially we set up isolation rooms, where the first three positive COVID-19 cases were diagnosed. Three weeks later, no staff or other patients who have used those exam rooms have become ill, thanks to increased cleaning and disciplined staff use of N95 masks, gloves and gowns. But nonetheless, we decided early on that any future testing must be moved outside.
The first challenge for holding clinic in the parking lot was that it was snowing that day. Regardless, we pushed through. I brought in 10 orange cones that I use to keep people from parking on my lawn on the 4th of July, and quickly set up our first curbside station at the Snow Mesa clinic. My staff accountant’s family retrofitted their invention that was originally meant to allow for up-close observation of hummingbirds into a protective helmet and mask for collecting the nasal swabs safely. The brave staffers who don the “hummingbird protection helmet” are paid hazardous duty pay.
Unlike the emergency room and CDC “free test,” which were not really available but did produce results almost overnight, our laboratory was not prepared at first. We saw four-day turnaround times for testing rise to almost 12 days, which we knew was agonizing for the patients waiting at home wanting to get back to work. And then the lockdown hit, so many could not work anyway. But essential workers were asking every day, “Is my test back yet?”
The first call from the laboratory came at 3 a.m., which could only mean one thing: Our first COVID-19 test resulted positive on March 23. And it was a health care worker from a nearby hospital system. She would not be returning to work.
As of April 9 we have tested over 130 people with 12 positive results and counting. All of the other negative tests were diagnosed with things like the common cold, adenovirus, influenza A and B, pertussis and RSV.
Painful staff furloughs – health care heroes taking one for the team
It was my decision. I laid them off. All 13. Sometimes I asked for a volunteer but most were involuntary.
On March 13, we had 64 employees. I diagnosed our company’s first case of COVID on March 23 but the Miramont staff furloughs started before then, on March 20. Then again on March 27. And again April 3. Everyone was hoping the furloughs will stop. Especially me. Because now we only had 48 people to do the work of what was once 64.
My team typically has one or two patients cancel per day. On top of this, Monday, March 16 was the first day of Spring Break and that week is always slower in clinic. That Monday there were six cancellations and 20 percent of our visits that day were converted last minute to remote video chat. By Wednesday it was 40 percent of the schedule. And by Friday, March 20, over half of the patients we cared for would be face-to-face only by a video screen.
Amanda, my aesthetics nurse, was squirming. She had left a skilled nursing facility to pursue her dream at Miramont of becoming a master Aesthetics RN. But other spas in our neighborhood had been ordered closed. Suddenly laser hair removal and Botox did not seem like a priority. Amanda knew that RNs were going to be needed more back in the nursing home to win the war on COVID. She was my first labor casualty.
Revenues started to drop and fast. Demand for COVID testing was high, but video chat do not pay as well as in-office visits, especially at Miramont where we are often performing labs, X-rays, mammograms and other important primary care services during the same visit. All that really can be done remotely is to charge for time. And the margins in primary care are razor thin. I always tell my staff and patients “being a family physician is like being a family farmer” – we doctor until the money is gone. But I also knew that running out of cash was not going to be an option.
My wife, Teresa, and I started Miramont with one employee and one computer back in 2002. We grew big and fast, and the strength of our success was not the high-tech tools we acquired, but the incredible Miramont family of staff who skillfully wielded those tools. We began 2020 with the lowest staff turnover we had seen in years. Nearly 20 percent of our workforce had at one time worked for Miramont, quit and then come back. The most common reason someone leaves Miramont is actually to pursue their career in health care. They were not quitting because they did not like the medical field. We have had so many staff go on to be psychologists, nurse practitioners, medical doctors, pharmacists and physician assistants.
But our biggest cost has always been labor. Payroll at Miramont is a staggering $3.6 million per year and a 25 percent reduction in revenue must have a 25 percent reduction in overhead, otherwise all is lost. To save the ship, some staff would have to be furloughed.
It was not a simple as across-the-board cuts. First of all, telehealth instantly changed our workflows. We needed medical assistants who could start the visit remotely just like in the office, but without coming to the office. And with people not coming in, phones had to be answered.
I started with reception team members, moving them to furlough, and then sending medical assistants to staff the phones. We would no longer have a call center. We would have a triage call center. Teams no longer needed two medical assistants and a scribe; we would pare each team to one medical assistant and a scribe. Schools closed. My workforce is 85 percent female, and the burden of having children at home fell disproportionately to young mothers. Anyone we could send home with a company phone and a laptop to keep working we would, but still there was not enough work. I looked ahead. Some of my physicians who normally would have 80 patients a week on their schedule now had only eight. Others went the other direction. One physician assistant added so many telehealth visits that he saw 39 patients in one day – double his normal volume. Those who were adopting would keep their jobs. I wanted to keep everyone but I could not. And it was all happening so fast.
“Do not take their faces off of the website,” I told my operations team. “Do not take their Miramont ID card, do not stop paying their benefits. We are going to hire them back. Plan for it.”
We made payroll this week but cash flow remains a week-to-week challenge as always. I don’t know what it will be like next month. When will we open up mammography and routine colonoscopy? Will Amanda be back from the nursing home before the summer? And for those on furlough, will they still want to come back to a place that let them go? Will they have enough money for their families this month on unemployment? Will the state of Colorado pay them on time?
We all want our life back. I just want my furloughed staff back. They are no less heroes than my curbside testers in protective face shield helmets. My furloughed staff are my heroes, because they are taking one for the team, to make sure there is a Miramont for all of us to come back to.