Guest commentary: Clear communication, not the 'medium' is key during COVID-19 pandemic
In this guest commentary, Narayanachar S. Murali, MD, FACP, FACG, DNBPAS, from the Gastroenterology Associates of Orangeburg in South Carolina , discusses how COVID-19 has impacted his private practice. He also explains how communication regardless of the mode — whether through telephone or through video conferencing — is very important during this pandemic to take care of patients properly.
I'm right on the ground, actually in the trenches, working daily, trying to keep my staff on their job and go home with a paycheck. I'm not a part of big hospital chain or a university where people are assured some pay, even if it is reduced during a crisis like this. I’m busy every day, trying to help my patients and also pay my bills. I have the same problem as any other small business owner affected by the COVID crisis. We have an added responsibility of delivering all of this in a humane way. If we just close shop, it’s not going to work. I am lucky that I have been in practice for so long and I have a reasonable cushion to stay open when the income falls suddenly. I had an open conversation with my staff when COVID-19 began. I did a “what-if” impact analysis if we had to close the practice for two months, four months or longer. We don’t have an enormous amount of money sitting around. Hopefully, with the promised government grants and other help, we can probably stay open.
Telephone vs. telescreen
How do you take care of patients if the office doors are physically closed? I understand telehealth. But the problem is we have been tossed into this mess with so many mandates, all of them lobbied in legislations. CMS has briefly “relaxed” these mindless definitions of what constitutes telemedicine. If I picked up the phone and had a lengthy conversation with a patient who doesn't have a screen in front of them or doesn't have the facility to use one, even if they had a smartphone, it could be considered a crime of improper billing under existing law as you cannot bill for it even if you document it properly.
My patients know me very well as I've been in practice for 30 years. They don't need to see my face. To hear my voice is assuring to them. We want our patients to have proper communication of what we are doing, and they also need to have an unfettered access to their secured physical chart. I explain what I'm doing in great depth and I always share the record with the patient. It has been my practice to send the records in a secure digital file (encrypted pdf file) to the patient so that they can actually see what was done. They do not have to log into portal or navigate menus. A patient can go through the record and if they have any questions, they can email me, or they can call me. They have my cell phone number, so it's easy for me to communicate with them. Many times, they come just for a follow up of the lab results, or a follow-up of a previous abdominal physical finding or to ask what exactly should be done about a test result or X-rays. Those are things I can handle on the phone in a few minutes. It saves time for me but before COVID-19 it used to be a non-reimbursed activity. It is hard for me to offer free advice because it will be tantamount to free service and nobody recognizes the technical knowledge and the cognitive expertise that you need to make such impactful recommendations on the phone or on the video.
The videoconferencing with an added time tracking billing tool was imposed upon doctors as a necessity to bill and to get paid. You have to document stuff like the time spent “face to face” with the patient. All this is very important for administrators. But it is not important to the patient or to me. Telemedicine will increase the cost of doing business if video conferencing is mandatory and doctors continue to think it wise to accept 50% payment for this service. The telephone is a tool. “Telescreen” is a tool. I don't know why one communication tool should be mandated over the other as long as we can communicate what is important and get the job done.
There's another layer of complexity while communicating with elderly people. They may be tech savvy in having the iPhone and doing a FaceTime chat. But when it comes to discussing medical problems, they get distracted. For example, if the video camera is not focused on my face, they are more focused on that. So that little distraction takes away the element of proper communication. It's easier to use the phone in these cases.
The phone is the perfect medium for doctors and patients who trust each other. There's no reason for insurers or administrators to come and tell me how to do my work. I take care of people in a modern office. I use technology appropriately and all my patients are connected to me, not always through video.
There's hardly anything that you can do on the video screen that you cannot through a phone. For example, if in some cases, I may want to see what they're talking about, like a lesion, I can turn on my video/FaceTime and say, focus your smartphone on that and I can look.
Private practice during pandemic
COVID-19 hasn’t changed my consultative practice too much. I have not been doing any elective procedures in the hospital or in my office-based surgery. This has taken a huge chunk off our income, but not affected taking care of patients and doing what is needed to assure them and help them with their medical problems. If they need to come see me, I schedule a visit for them to allow distancing and we will take care of them safely. There is less panic here than in New York City, but everybody's very careful. The office is running, and I am still paying all my employees full time salary and paying the bills. I want to make sure the staff is happy. Only two staff members are here at any given time instead of the whole office. I'm taking care of patients on phone or video. I usually finish by midday.
Pose the same question to a hospital-employed doctor. Redundant staffing is the norm in hospital practices. A typical professor would have a nurse practitioner or a physician assistant, they are able to use all these people to do different tasks including video consults and sign off on these activities electronically. Hospitals are also paid about 2.5 times what private practitioners are paid by insurers for the same service. We all need to understand what the job is to be done and how do I do it with the least number of interruptions and at the lowest cost. There is no reason to pay less for a consultation if delivered on the phone vs. in person. The success of my practice depends on direct and clear communication with the patients. If I don't communicate, the patient won't come to me. I use end to end encrypted services like WhatsApp, Skype and Facebook, often to help patients all over the world. Administrative types throw HIPAA everywhere, and it has nothing to do with communication. For example, a typical electronic medical record video chat is less secure than a phone call. Voice over internet protocol phone calls, WhatsApp, Skype, EMR chats are encrypted end to end, but the video conference can be more easily hacked. Patients want care with the least hassles, I am willing to offer medical care when needed and I should be justly compensated for my expertise, training and the cost of being in business. I can't offer that as a free service or service at half price just because Medicare thinks it's not important. This also brings forth the problem of third-party payment systems. When you don't have a third-party payment system, patients will seek value in the care they want. They will get the care they need at the price that they want.
COVID-19 may force us to re-examine everything the medical–industrial complex has felt was “important enough” to create lobbied-in rules. What we have accepted as “insurance coverage” may change, hopefully for the better. We shall see where this goes.
Disclosure: Murali reports no relevant financial disclosures.