Interim Guidance for Reopening the Health Care System & Best Practices for Reopening from COVID-19

MSSNY SEAL

We thank MLMIC and the California Medical Association for their valuable contribution to the following guidelines.

As the COVID-19 pandemic spread throughout the world, New York and the United States took steps to limit the transmission and impact of the virus by implementing shelter in place orders. However, due to travelers coming in from Europe, New York became the hotbed and epicenter of the COVID-19 Pandemic.

New York saw a major increase in hospitals admissions and shortages in personal protective equipment.  The pandemic caused many other parts of the health care system to be idled in order to preserve resources and capacity in the system and limit opportunity for transmission or exposure to the virus.

Physician practices and health care facilities have seen massive drops in patient visits, caused by a combination of shelter in place orders and patient fear. This may lead to much  more complex  problems in the future, as patients miss routine screenings and preventative care. With proper safety precautions,  a doctor’s office is one of the safest places for a patient. Reopening physician offices is an important step for New York State.

The Medical Society of the State of New York (MSSNY) proposes several steps to reopen New York’s health care system in a manner that should benefit the health care workforce and the patients you serve.  MSSNY recommends the following:

+   An ongoing and responsive public education is key to reopening the health care system: Our understanding of COVID-19 transmission, testing and treatment is rapidly changing and evolving. Reopening the health care system will take a concerted public awareness campaign to educate patients and the public when it is safe to seek care in their physician’s office or other health care setting. The public messaging must be responsive to changes in testing and treatment as well as the ebbs and flows of the disease.

+   Reopening the health care system will vary based on geography and local conditions: When the health care system can open and to what degree will be highly dependent on local conditions. The transmission and prevalence of COVID-19 has varied across the state and within counties and cities. It is highly critical that communities continually evaluate conditions and the impacted populations and make recommendations accordingly. Local communities should be prepared to adjust preventative measures and recommendations rapidly and be responsive to changing conditions.

+   Ensuring adequate capacity in the health care system: The health care system needs to inventory available capacity to meet current demand while maintaining capacity for future surges including PPE, testing and treatment supplies as well as staffing capacity. Special consideration should be made to ensure staff are given resources to support resiliency.

+   Federal and state regulatory flexibility should be maintained, in particular telehealth payment parity must be maintained: Regulatory flexibility has allowed practices to adapt to changing conditions and continue to see patients while either they themselves may have been exposed to COVID-19 or to prevent exposure for their patients through telehealth. This has allowed for screening and initial treatment of patients for COVID-19 but also managing of unrelated acute or chronic conditions. Similarly changes in reimbursement around cost sharing for testing and treatment or billing have enabled patients and physicians to seek and bill for care and the reduced administrative burden allows physicians to focus on patient care. These regulatory flexibilities must be permanently maintained to allow for the health care system to be agile and responsive to changing conditions.

+   Widespread practice level safety protocols: As physician practices and health care facilities reopen, every precaution should be taken to minimize the risk of infection, for both office staff and patients. MSSNY recommends that all practices and facilities adopt comprehensive safety protocols including managing patient flow, limiting visitation, checking temperatures, remote check-in, etc.

+   Reopening should be in phases based on testing, treatment and data: The health care system should reopen in phases based on data and information around the prevalence of the disease, immunity, and available treatment. This will continue to change as the science, availability and accessibility and testing and treatment evolves. Certain sub-populations may be recommended to be seen first based on risk status (i.e. pediatrics who are low risk) or need (i.e. chronic conditions or delayed treatment).

Background

On April 16, 2020, President Donald Trump released his set of guidelines for “Opening Up America Again.”  The President’s document suggests reopening the country in phases, allowing for regional variations depending on the prevalence of the disease in different states and regions.

As the federal and state governments begin to have conversations about relaxing shelter in place orders, the health care system will face a unique set of challenges. While emergency departments and intensive care units (ICUs) have been overwhelmed with COVID-19 patients, many other parts of the health care system have been idled to preserve resources and capacity in the system. As the crisis set in, hospitals almost immediately began to cancel elective, non-urgent procedures. Many physician practices, facing shelter-in-place orders, have either completely closed or moved as much of their care as possible to telehealth. Now, unused capacity will need to be brought back online, gradually and with caution.

MSSNY offers the following Guidelines & Recommendations for Reopening the Health Care System. It is MSSNY’s hope to speak both to policymakers, who are looking at health care in the context of the larger reopening of society, and physicians, who are considering how to restart their practices.

Considerations for Opening the Health Care System

1.     Ongoing and Responsive Public Education Will Be Key to Reopening the Health Care System

Our understanding of COVID-19 transmission, testing and treatment is rapidly changing and evolving. Reopening the health care system will take a concerted public awareness campaign to educate patients and the public when it is safe to seek care in their physicians’ office or other health care setting.

At the outset of the pandemic, the Centers for Medicare and Medicaid Services (CMS) and many other governmental bodies recommended that health care providers delay or cancel elective procedures to preserve capacity in the health care system. Patients, already fearful due to media coverage of the virus, heard these recommendations and avoided the health care system all together. This has led to even needed care, including emergent care, being delayed or put off. There are anecdotal stories of patients dying in their homes because they were afraid of going to the doctor.

Physicians are concerned that the compounded effect of delayed care will further delay the process of reopening the health care system. The patients who present when an office reopens may have advanced problems that could have been mitigated through the provision of routine care. Public health officers throughout the state have already begun educating patients that they can and should seek help for urgent needs.

Now, as the health care system begins to reopen, patients will need additional reassurance that it is safe to seek care. Policymakers, medical associations, and physician practices can all play a role in helping patients understand the precautions that are being taken to keep everyone safe. They can also help educate the public about the importance of seeking regular, routine care, even during the pandemic.

This may include phased implementation that encourages chronic care management or wellness visits for less vulnerable populations. It also will likely have to adapt to potential future surges in COVID-19 prevalence. Coordinated and responsive messaging and communications is a necessary condition to reopening the health care system.

2.     Widespread Availability of Testing and Data

In order to understand when and how we can reopen the health care system we will need adequate testing, data and analytics to understand the prevalence and true risk of the disease including immunological response in the community. This requires widespread, accessible and affordable testing as well as accurate data, reporting and analytics. Evaluating data will help the health care system create regionally and population-based recommendations that minimize risk to the extent possible but allow for others to access care.

3.     Assessment of Health Care System Capacity, Including the Availability of PPE

The health care system should only reopen if there is adequate capacity to support potential future surges. This would include beds, staffing, and, as described below, personal protective equipment (PPE). It is possible that the success of physical distancing in this state has created some capacity for the health care system to move back into elective care. But this must be approached with caution and continuously monitored.

A key consideration when assessing health system capacity is the very likely resurgence of the disease. This could come either from the loosening of physical distancing requirements or from cooler temperatures in the Fall and Winter of 2020. As the Governor has correctly called out, society needs to be prepared to reinstate pandemic protocols if the infection rate begins to climb back up. Similarly, health care facilities and practices need to approach scheduling of delayed care with thoughtfulness and caution, maintaining an ongoing supply of ventilators, beds, staff time, and other resources are needed to combat a resurgence of COVID-19.

Another important facet to this discussion is the availability of PPE. The State of New York has, especially New York City, had a difficult time in acquiring and distributing PPE during the worst days of the pandemic. Now, facilities and practices need to carefully consider whether the flow of PPE is sufficient to allow for the reinstatement of some elective care.

4.     Continuation of Regulatory and Payment Flexibilities Indefinitely

A. The Federal and State Government Should Continue Telehealth Parity Rules 

Since the outset of the pandemic, both the federal and state governments have promoted telehealth to allow physicians to continue treating patients while complying with social distancing. Both CMS and the State of New York have waived consent policies, implemented payment parity, and expanded the services that can be provided remotely.

The result of all this effort has been a massive and rapid expansion of the use of telehealth. Physicians and patients are quickly adjusting to virtual care as a treatment modality.  Telehealth is a genie that will not go back in the bottle.

In order to preserve the progress that has been made during this time, both the federal and state governments should move to make permanent the policy changes that have been put in place during the pandemic. In the short term, this will allow physicians to continue treating some patients remotely. Longer term, it will cement the changes that have been made to the health care system over the past two months and allow virtual care to flourish.

B.    All Payers Should Continue Administrative Efficiencies Instituted for the Pandemic 

Along with reimbursement rules, many private and public payers have instituted administrative efficiencies for physicians which should be extended past the end of the pandemic. For example, CMS allowed the Department of Health to waive prior authorization requirements in the Medicaid fee-for-service (FFS) delivery system and offered extensions for pre-existing prior authorizations in Medicaid FFS through the end of the declared public health emergency. As many of these efficiencies as possible should be made permanent, to allow physicians to plan their practice workflow for the future.

5.     Reopening Must Be Inclusive of Different Practice Sizes and Settings

To date, there has been an understandable focus on restarting elective surgical procedures. Elective procedures were cancelled almost immediately at the outset of the pandemic, to conserve hospital capacity and resources for COVID-19 patients. As New York considers reopening, however, the state must consider the crucial role played by physicians in all modes of practice. Small practices have been unduly impacted by shelter in place orders, as they have been unable to treat patients for more than a month.

New York cannot afford to lose these essential health care providers. As the health care system reopens, there may be a “second surge” of patients who flood the system seeking delayed care. Small practices, FQHCs, and other ambulatory settings will absorb the brunt of that second wave of patients. In addition, they will often be the providers tasked with coordinating care for patients who come out of the ICU after a bout with COVID-19.

Recommendations for Reopening the Health Care System

1.     Universal Safety Protocols at the Practice and Facility Levels

As physician practices and health care facilities reopen, every precaution should be taken to minimize the risk of infection, for both office staff and patients. MSSNY recommends that all practices and facilities adopt comprehensive safety protocols. Below is a list of best practices. A list of recommended protocols is included as Appendix A.

2.     Use a Phased Approach Based on Local Circumstances

The size and scope of the COVID-19 Pandemic in New York calls for a regional, phased approach that recognizes local circumstances in the various parts of this diverse state.

The coronavirus has not hit all regions of New York with the same ferocity. New York City, Nassau, Suffolk and Westchester Counties were hardest hit.

Of course, the raw number of infections is only one data point that the state should consider when assessing where and how much to reopen the health care system. While rural communities have lower infection rates, they also have less capacity to handle an outbreak. The physician workforce in many rural communities is older, and there are far fewer hospital beds and ventilators.

Seeing this wide variation, MSSNY supports the use of a regional, phased approach to reopening the health care system in this state. This approach should consider a multitude of factors, including:

+   Number of infections, by population

+   Trends in hospitalization and ICU beds

+   Demographics of the local population

+   Local health system capacity

Counties and regions that can show positive trend lines combined with health system capacity should be the first in line to reopen non-COVID-19 care.

3.     Special Care Should be Given to Vulnerable Populations

MSSNY recognizes the unique needs of vulnerable populations in any plan to reopen the state. Similarly, the health care system needs to be sensitive to the elderly, immunocompromised, and other sensitive populations. The Coronavirus is particularly dangerous to these populations. And these patients are possibly the least likely to be able to access telehealth.

As practices and facilities reopen, they must be mindful of the risks for these populations. For example, many practices can consider setting aside office hours to only see elderly or infirm patients. Or they could keep special entrances and exam rooms only for vulnerable patients.

4.     Prioritizing Delayed Care

During the time that the shelter in place order has been in effect, the health care system has been building a backlog of delayed care. Over time, that backlog has grown very large. The entire health care system will need to work with policymakers to work through the backlog in an orderly fashion. MSSNY recommends that the following types of care be prioritized:

A.    Priority Should be Placed on Reopening Pediatric Practices 

Many pediatricians have seen their practices brought to a standstill. Parents had an understandable fear about exposing their children to infection, and many pediatric services cannot be done through telehealth.

MSSNY is concerned that the shutdown of pediatrics will cause severe problems in the future. For example, without well child visits, many young patients are not receiving their recommended vaccinations. This puts them and the community at risk of outbreaks of preventable diseases (measles, whooping cough, etc.).

There is also evidence that the shutdown of pediatric practices has caused a drop in child abuse reporting. Cases of abuse are often caught during well child visits, which are not routinely happening. These children are being left at risk.

In addition, teenagers are at particular risk for mental health problems that are not being routinely seen or treated. The stress of the pandemic, combined with being cut off from social supports, may be exacerbating these problems.

Physicians and policy makers should begin an education campaign for parents that it is safe for their children to see their physicians. Practices can support this effort by explaining to families the steps they are taking to keep their patients safe.

B.    Prioritize Preventative Care 

The vast majority of delayed care is routine, non-urgent preventative care and screenings – mammograms, colonoscopies, etc. These procedures, while not urgent, can identify serious health issues before they reach a crisis point. Preventative care also includes care management for patients with chronic conditions. Regular check ups for patients with conditions such as Cancer and Diabetes are an important part of the standard of care.

As New York reopens the health care system, practices and facilities should – with proper safety precautions – put a priority on scheduling patients for these important screenings.

C.    Support the Elective Surgery Guideline Published by the Surgical Specialties, with Regional Input from the County Public Health Officers

MSSNY supports the Joint Statement on Resuming Elective Surgery published by the American College of Surgeons, American Society of Anesthesiologists, Association of Perioperative Registered Nurses, and the American Hospital Association. This document presents a logical

and reasonable approach to bring back these important procedures. Facilities can also consult the CMS recommendations on re-opening facilities.

Here again, however, a regional approach will be essential. Every county in New York had an order from the Governor to stop elective surgeries.  The access to resources such as PPE and hospital beds varies widely across the state.

The state will need to coordinate closely with the County Public Health Officers to react to local needs as hospitals begin to schedule elective procedures.

Conclusions

Reopening the health care system after a prolonged shut down will be neither an easy nor a fast process. MSSNY supports a phased, flexible approach that combines public awareness campaigns that physician practices are open, with changes to those practices to ensure that they are safe. The state must use a phased, regional approach that recognizes the wide variation in the health care system in this state. The approach should focus on prevention and care for the most vulnerable patients.

MSSNY looks forward to working with policymakers, physicians, and the entire health care system to reopen safely.

Universal Safety Precautions for Practices and Facilities

As physician practices and health care facilities reopen, every precaution should be taken to minimize the risk of infection, for both office staff and patients. MSSNY recommends that all practices and facilities adopt comprehensive safety protocols. Below is a list of best practices.

1.     Educate Patients about Your Safety Protocols, and How They Can Help

As practices reopen, they should communicate with their patients clearly about their safety protocols. As described below, many of the changes a practice might make will require patients to change their usual routines. Informing them upfront will serve to allay their concerns and ensure that they are properly prepared.

2.     Maintain Physical Distancing

Physician office space and workflow should be structured to encourage physical distancing. Here are a few ideas for practices to consider:

  • Ask patients to check in by phone or text message and wait in their car until an exam room is
  • Prohibit adults and teens from having guests or Only parents with younger children should be in the office.
  • Schedule patients so that only a few are in the office at any one
  • Put away articles such as magazines, toys, coffee, or anything else that may be handled by infected
  • If possible, arrange office flow such that patients enter and leave through separate
  • As able, modify check-out procedures to minimize/avoid any patient time in central area or at check-out
  • Consider setting aside clinic hours for vulnerable patients – elderly, immuno-compromised,

3.     Require Universal Masking

Practices should require everyone who enters the practice – both patients and staff – to wear an appropriate face covering. Physicians should communicate this requirement to patients at the time of scheduling an office visit. Patient communications should also include education about the proper type of face covering. Patients do not need n95 masks, which should be reserved for health care workers.

Practices should be aware of the needs of very young children and those with respiratory diseases, who may face difficulties with reduced airflow through face coverings.

4.     Continue to Use Telehealth, as Appropriate

With the support of regulatory guidance and waivers, the health care system has made a massive shift to the use of telehealth. For all “no-touch” services, physicians should continue to engage in virtual care. This will have the effect of limiting the number of patients who appear in the office and preserving precious office time and space for patients who must be seen in person.

5.     Pre-Screen Patients for Possible COVID-19 Symptoms

At the time of scheduling, patients should be asked if they are experiencing common COVID-19 symptoms – dry cough, fever, etc. All patients, regardless of symptoms, should have their temperature checked as they enter the office. Patients displaying COVID-19 symptoms should be screened telephonically, and tested if possible, before coming to the office.

6.     Preservation of Personal Protective Equipment (PPE)

All staff should be trained on the proper use of PPE. Practices should follow CDC guidelines for extended use and reuse of PPE

7.     Give Extra Care and Attention to the Emotional and Physical Needs of Staff

The pandemic has required physicians and many other health care workers to work long hours in dangerous conditions. As the health care system reopens, practices should pay extra attention for signs of exhaustion, depression, stress, and other similar issues.

8. Clinical Staff

Verify that the clinical employees still have active licenses, registrations, and/or certificates.

9. Insurance and Business Continuity

Reinstate any professional liability, general liability or other relevant business insurance programs that may have been reduced or suspended during the closure.

10. Consider completing a risk management self-assessment


PART II

BEST PRACTICES FOR REOPENING FROM COVID-19

As the COVID-19 pandemic spreads throughout the world, New York and the United States took steps to limit the transmission and impact of the virus by implementing stay at home orders. However, due to travelers coming in from Europe, New York became the hotbed and epicenter of the pandemic for the United States.

New York saw a major increase in hospital hospitals admissions and a significant shortage of personal protective equipment (PPE).  The pandemic caused many other parts of the health care system to be idled in order to preserve resources, preserve the capacity of the system and limit opportunity for transmission or exposure to the virus.

As physicians begin to approach safely and cautiously reopening their medical practices for office visits, the Medical Society of the State of New York (MSSNY) respectfully offers the following list of best practices.

Steps to Take Prior to Reopening a Practice

1.     Consult the Local Public Health Department

New York issued statewide stay-at-home orders.  However, when and to what extent a practice can reopen for patient visits will depend on local orders and conditions. MSSNY recommends that all physicians consult their local public health departments for guidance on the rules in their area.

2.     Construct a Financial and Staffing Plan for Reopening

Practices that have shut down completely will need to plan for a gradual reopening. It is likely that patient volume will return slowly, and the office may not need to be fully staffed at all times.

Practices should plan both their finances and staffing to account for this reality. See Financial and Staffing sections for more detailed recommendations.

3.     Develop Safety Protocols

Patients may be fearful about interacting with the health care system. With proper safety precautions in place, a physician’s office is one of the safest places a patient can be. See Universal Safety Precautions for Practices and Facilities for a list of best practices, developed by the MSSNY for Reopening the Health Care System.

4.     Assess the Supply of Personal Protective Equipment

Both the federal Centers for Disease Control and Prevention (CDC) 1 and the New York State  Department of Health have published guidelines for the use of personal protective equipment (PPE).

     https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html 

Physicians should assess their supply of PPE based on these guidelines, with some margin in case of a disease outbreak.

5.     Consider the Role Telehealth Will Play in Reopening

During the pandemic, many physicians have either implemented or expanded the use of telehealth to continue seeing patients. Practices who have not yet implemented telehealth may wish to consider how it can support safe patient care during reopening. Practices that have implemented telehealth can work on moving to a hybrid model, with patients seen both in office and virtually.

For more information on implementing and using telehealth, please see the MSSNY website for telemedicine information.

6.     Clearly Communicate with Patients about Practice Changes

As practices reopen, they should communicate with their patients clearly about their safety protocols. As described below, many of the changes a practice might make will require patients changing their usual routines. Informing them upfront will serve to allay their concerns and ensure that they are properly prepared.

7.     Be Watchful of Medication Shortages

Patients coming back to their doctors, combined with potentially compromised supply chains, may make it difficult for patients to get their usual medication. Physicians should consider alternatives and set expectations with patients if medications become unavailable.

Financial Considerations

1.     Consider the Capital Needs of the Practice and Available Funding Sources

As practices reopen, revenue and patient volume may increase slowly and unevenly. Physicians should carefully consider their capital needs for reopening, and all available funding sources, both private (bank loans) and public (such as SBA loans or government grant funds).

For more information about financial resources that can support practices, please see MSSNY’s website information.

2.     Address Accounts Payable

Organize your accounts payable and develop a plan to repay any vendors in which you deferred payment including rent, utilities, vendors, Centers for Medicare and Medicaid Services (CMS) advanced payments or any other payer advanced payment or loans. Maintain open lines of communication with payers and vendors on payments due that you may need to defer.

3.     Plan to Meet Existing Obligations

Practices should review contractual obligations from managed care payers, such as timely filing limits for claims and appeals, or submission of any encounter and/or quality data required. It is also a good idea to check employment agreements, vendor contracts and lease agreements. Reviewing these agreements and contracts for any clauses regarding termination, late payments, late fees, interest, etc. can save bigger headaches down the road. Maintain open lines of communication with payers and vendors on reporting or other obligations that you may not meet.

4.     Develop a Monthly Budget

This will help on a going forward basis as things move to normal business. Practices can identify what costs the most on a monthly basis and adjust as necessary.

5.     Talk to Vendors

If vendors know that the office is reopening, and will have revenue again, they may be willing to negotiate reduced rates, deferred payments or other considerations. Practices should contact vendors and see what they are offering to help with startup of the medical practice.

6.     Tackle Accounts Receivables Slowly

As the office reopens, practices should continue or re-start collection activity and implement an internal process to follow up on outstanding claims. Office staff can pull financial reports (Insurance Aging, Patient Aging, Adjustment Report, ideally starting in the 60 day and older aging buckets).

The goal should be to make sure every claim has been followed up on patient schedules for the upcoming one or two weeks.

7.     Verify Patient Contact and Insurance Information

When patients return to the office, their life circumstances may have changed. Office staff should confirm patient contact information, including address and phone number. Patient insurance eligibility and benefits should be checked to determine if eligibility is effective, or if copay and deductible amounts have changed. If patients have an outstanding balance, practices can offer payment plans. It is important to communicate with patients at the time of confirming appointments.

8.     Analyze Revenue Streams

Billing staff should understand the Days Revenue Outstanding (DRO), which is the average number of days it takes to collect on the practice’s accounts receivable. It is important to have an accurate understanding of revenue streams as payments may have been delayed, compared to past revenue trends, or incorrect due to payer delays in implementing telehealth requirements or other related factors.

Staffing Considerations

1.     Right Size Physician and Staff Work Force

As noted above, practice revenue and patient volume may come back slowly, in cycles and unevenly. To prepare for this, practices should consider staffing adjustments, which may include bringing staff and physicians back in different waves. Personnel can be placed on rotating teams or via telecommuting for certain positions if possible.

2.     Consider Options for Vulnerable Staff

Working in health care immediately puts health care workers at risk and at higher exposure. The risk is even higher for vulnerable staff – those over the age of 60 or with pre-existing conditions. Having internal policies for these workers can help all employees feel safe while working.

Workers in vulnerable populations may be shifted to different roles that minimize their risk of exposure. This may include various duties, such as consulting with younger staff, advising on the use of resources, keeping staff updated on most recent news, ordering of supplies for the clinic, working from home, phone triage of patients, helping providers and managers make tough decisions, or talking to patients’ family members.

3.     Give Extra Care and Attention to the Emotional and Physical Needs of Staff

The pandemic has required physicians and many other health care workers to work long hours in dangerous conditions. As the health care system reopens, practices should pay extra attention for signs of exhaustion, depression, stress and other similar issues.

Practices looking for resources on addressing the mental and emotional needs of their staff should contact the MSSNY Wellness here.

http://www.mssny.org/MSSNY/Practice_Resources/Physician_/Physician_Burnout_Library_.aspx

Universal Safety Precautions for Practices and Facilities

As physician practices and health care facilities reopen, every precaution should be taken to minimize the risk of infection, for both office staff and patients.  MSSNY recommends that all practices and facilities adopt comprehensive safety protocols. Below is a list of best practices. Some of the recommendations below may not apply to certain practices, so physicians and office staff should adjust them for individual circumstances.

1.     Maintain Physical Distancing

Physician office space and workflow should be structured to encourage physical distancing. Here are a few ideas for practices to consider:

  • Ask patients to check in by phone or text message and wait in the car until an exam room is
  • Prohibit adults and teens from having guests or Only parents of younger children should be in the office with the patient.
  • Schedule patients such that only a few are in the office at any one Practices can consider offering evening and weekend hours and leaving more time in between patients.
  • Put away articles such as magazines, toys, coffee, or anything else that may be handled by infected
  • If possible, arrange office flow such that patients enter and leave through separate
  • As able, modify check-out procedures to minimize/avoid any patient time in central area or at check-out
  • Consider setting aside clinic hours for vulnerable patients – elderly, immunocompromised,
  • Separate patients with respiratory symptoms so they are not waiting among other patients seeking care.
  • Consider strategies to prevent patients who can be seen at home via telehealth from coming to your facility, potentially exposing themselves or others to germs.

2.     Require Universal Face Covering

Practices should require everyone who enters the practice – both patients and staff – to wear an appropriate face covering. Physicians should communicate this requirement to patients at the time of scheduling an office visit. Patient communications should also include education about the proper type of face covering. Patients who are not ill do not need N95 or surgical masks, which should be reserved for health care workers. Practices should be aware of the needs of very young children and those with respiratory diseases, who may face difficulties with reduced airflow through face coverings.

3.     Implement Strict Sterilization Procedures

Physician offices and health care facilities are already cleaned and sterilized more than most communal spaces. Lowering the risk of infection, however, will involve even more strict sterilization protocols. Staff should familiarize themselves with the CDC Guidelines for  Cleaning and Disinfecting of Community Facilities.

4.     Continue to Use Telehealth, as Appropriate

With the support of regulatory guidance and waivers, the health care system has made a massive shift to the use of telehealth. For all “no-touch” services, physicians should continue to engage in virtual care. This will have the effect of limiting the number of patients who appear in the office and preserving precious office time and space for patients who must be seen in person.

Practices that are continuing to use telehealth find it helpful to schedule blocks of time (two or three hours) exclusively for virtual care. Staying in one modality at a time may be easier than moving back and forth.

5.     Pre-Screen Patients for Possible COVID-19 Symptoms

At the time of scheduling, patients should be asked if they are experiencing common COVID-19 symptoms – dry cough, fever, etc. All patients, regardless of symptoms, should have their temperature checked as they enter the office. Patients displaying COVID-19 symptoms should be screened telephonically, and tested if possible, before coming to the office. Physicians should keep up to date on the recommendations for preventing spread of COVID-19 on CDC’s website.

Guidance on COVID-19 testing is available.

6.     Preservation of Personal Protective Equipment

All staff should be trained on the proper use of personal protective equipment. Practices should follow CDC guidelines for extended use and reuse of PPE.

7.     Establish a Quarantine Policy

Practices should have a policy for workers who have contracted COVID-19, or show symptoms that they may have contracted it, requiring a 14-day quarantine.

Additional MSSNY Resources

MSSNY has developed comprehensive resources to help physician practices through the COVD-19 pandemic and beyond. These resources are updated daily, to reflect the most up-to-date information on this ever-changing situation. Practices can visit mssny.org/Covid-19 for the latest news and most up-to-date tools.

 

 

 

 

 

 

MSSNY Objects to Ambulatory Surgery Center Exclusion for “Elective” Surgeries


MSSNY Seal
MEDICAL SOCIETY OF THE STATE OF NEW YORK
865 Merrick Avenue, Westbury, New York 11590-9007
www.mssny.org
Communications Division
Telephone: (516) 488-6100

 

For Immediate Release
May 1, 2020 

MSSNY Objects to Ambulatory Surgery Center Exclusion for “Elective” Surgeries

Statement Attributable to:
Art Fougner, M.D.
President, Medical Society of the State of New York

“MSSNY has reached out to Governor Cuomo and to the New York State Department of Health to more clearly understand the rationale behind the seemingly arbitrary exclusion of Ambulatory Surgery Centers from Executive Order 202.25 that permits “elective” surgeries in selected counties across New York State where there is a reduced threat of a coronavirus surge.

“We were perplexed to see that such procedures could only be performed in hospitals, rather than other facilities regulated by the New York State Department of Health that regularly provide outpatient procedures. MSSNY and other specialty societies believe that there is compelling need to permit their patients in these 35 counties to be able to receive needed treatment to address their patients’ pain needs and other serious medical conditions that are adversely affecting these patients’ lives.

“To be clear, elective does not mean ‘not medically necessary’.  Patients in these counties deserve to have the choice to receive these services in facilities where there is likely less risk of inadvertent coronavirus transmission, provided certain protocols are met to protect these patients’ health.

“We look forward to further fruitful discussions to better ensure patients can receive the care they need in the most appropriate care setting.”

# # #

About the Medical Society of the State of New York
Founded in 1807, the Medical Society of the State of New York is the state’s principal non-profit professional organization for physicians, residents and medical students of all specialties. Its mission is to represent the interests of patients and physicians to assure quality healthcare services for all.

MSSNY Contact:
Roseann Raia
Communications / Marketing
Medical Society of the State of New York
865 Merrick Ave.
Westbury, New York
516-488-6100 ext 302
rraia@mssny.org

 

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COVID-19 Update May 1, 2020

MSSNY Legislative Podcast


New York State COVID-19 Stats

NYSDOH COVID-19 Tracker – NY.gov


Highlights: Gov. Cuomo’s Press Conference Today

  • New York reported 289 deaths related to COVID-19 in the past 24 hours. The rate of hospitalizations and net change of hospitalizations continue to trend downward, while the number of new COVID-19 patients remains flat.
  • Overall hospitalizations in the state have been well below original projections made at the outset of the pandemic. Cuomo said, by practicing social distancing, New Yorkers likely helped save close to 100,000 lives.
  • The next steps the state will need to take involve addressing the new daily cases – which have hovered between 950-1,100 for several days.
  • The majority of new cases are in the downstate region.
  • Schools across New York will remain closed for the remainder of the academic year.
  • K-12 and college facilities will continue to provide distance learning for rest of academic year
  • The governor says schools will still be required to execute meal provision plans, as well as assist in childcare options for essential workers.
  • Schools and colleges will be required to come up with plans to eventually reopen in ways that do not put students and essential workers at risk; those plans will need to be approved by the state before they can be carried out.
  • It is not yet clear when a decision will be made on the 2020-2021 academic year, but he added that schools should start planning sooner than later.
  • Some businesses may be able to reopen in some regions of the state depending on specific factors, such as the virus’ local impact, around May 15.

Gov. Permits Limited Resumption of “Elective” Surgeries; MSSNY Objects to ASC Exclusion
Governor Cuomo put forth an Executive Order this week permitting the resumption of elective surgery in 35 counties across upstate New York, where there is less of a chance of a coronavirus surge, including Monroe and Onondaga counties.  Of particular concern was the limitation on resumption of elective surgery in these counties to hospitals only, not Ambulatory Surgery Centers and office-based surgery locations that are often owned by physicians.

MSSNY President Dr. Art Fougner was quoted in the Utica Observer-Dispatch about the adverse impact of this limitation on patients obtaining needed care across Central New York, and issued a statement today (LINK) calling for this arbitrary exclusion to be eliminated so that patients have a choice in these counties as to where they can receive these needed surgeries.  Physicians can send a letter to the Governor expressing their concerns here: https://p2a.co/WOOJcvS

The guidance from DOH permitting the limited resumption of elective surgeries does provide important clarification to perhaps address some confusion as to what specifically was prohibited.  The guidance notes that the prohibition does not prevent hospitals, ASCs and OBS from performing surgeries and procedures related to the diagnosis of cancer such as lumpectomies and biopsies, the treatment of intractable pain, or other diagnostic and treatment services for highly symptomatic patients. It also includes a grid of examples to help guide treatment or delay decisions.


Medicare to Increase Payments for Audio-Only Telehealth
In response to advocacy by organized medicine, the Centers for Medicare & Medicaid Services (CMS) announced this week that it will be increasing payments for audio-only telephone visits between Medicare beneficiaries and their physicians to match payments for similar office and outpatient visits.

According to the American Medical Association (AMA), this would increase payments for these services from a range of about $14-$41 to about $46-$110, and the payments are retroactive to March 1, 2020.  This is a major victory for organized medicine that will enable physicians to care for their patients, especially their elderly patients with chronic conditions who may not have access to audio-visual technology or high-speed Internet.


NYSDOH Weekly Update for Physicians on YOUTUBE
April 30: Weekly Update to Healthcare Providers

Watch the webinar on YouTube.

Purpose: The purpose of this weekly publication is to provide healthcare providers in New York State with a consolidated update of guidance released by the New York State Department of Health (NYSDOH) related to the COVID-19 pandemic response. This will show only current guidance for any given topic and will be updated to reflect new guidance.

As a reminder, all advisories and informational messages (including webinar invitations) are distributed through the Integrated Health Alerting Network System (IHANS), an application housed on the Health Commerce System (HCS). If you are not receiving IHANS notifications, please work with your site’s HCS coordinator. Additional COVID-19 resources may be found on the NYSDOH webpage under Information for Healthcare Providers.

Recordings of COVID-19 Weekly Healthcare Provider Updates are also available on the NYSDOH


Paycheck Protection Program (PPP) Update
Have you applied for the PPP small business forgivable loan program yet?  According to SBA.gov as of 5:00 PM yesterday more than 960,000 loans had been approved totaling greater than $90 billion. The total number of lenders involved in processing these transactions has been 5,300 so far. Last week Congress approved an additional $310 billion for the program.

Yesterday, the SBA notified borrowers and lenders that certain provisions would be put in place to favor lending from smaller institutions. The text of the notice:

Paycheck Protection Program (PPP) Lending Operations Update – Wednesday, April 29, 2020

SBA and Treasury value all lenders and their small business customers.

To ensure access to the PPP loan program for the smallest lenders and their small business customers, starting at 4 p.m. today EDT through 11:59 p.m. EDT, SBA systems will only accept loans from lending institutions with asset sizes less than $1 billion.

Please note, lending institutions with asset sizes less than $1 billion will still be able to submit PPP loans outside of this time frame. Please also note that lenders with asset sizes greater than $1 billion will be able to submit loans outside of today’s 4:00 PM -11:59 PM EDT reserved processing time.

This reserved processing time applies today April 29, 2020. SBA and Treasury will evaluate whether to create a similar reserved time again in the future.

SBA and Treasury continue to monitor loan system performance and will continue to provide frequent updates to the lending community.


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Garfunkel Wild One-Hour Webinar: The Enforceability of Employment Contracts During the COVID-19 Pandemic on Monday May 4 @12 noon-1pm

Speakers:  Andrew L. Zwerling and Roy W. Breitenbach

Garfunkel Wild’s Andrew L. Zwerling and Roy W. Breitenbach will present the webinar “The Enforceability of Employment Contracts During The COVID-19 Pandemic” on May 4, 2020.

Among the many impacts of the COVID-19 pandemic has been the steep rise in concern over the viability of employment contracts. Businesses of all types, in all industries, have experienced business and financial disruption of profound magnitude that has compelled them to take action of various types that, on their face, violate the plain language of employment contracts of which they are a part.

Salary reductions, work reductions, terminations without requisite notice, job furloughs and similar actions that on their face violate contractual obligations have become commonplace as businesses try to stay viable, if not operationally functional, during the COVID-19 crisis. This raises certain obvious questions: despite running afoul of the plain language in employment contracts, are such actions nonetheless proper given the impact of the pandemic? Are parties obligated to perform their obligations under employment contracts given the constraints imposed by governmental orders and other fallout from the pandemic or are they discharged from such obligations? Does it matter that there is a force majeure provision in my contract? What happens if the employment contract does not have a force majeure clause?

We will conduct a webinar that will address these issues and others, including the applicability of doctrines of impossibility of performance, impracticability of performance and frustration of performance, and the effect of force majeure clauses.

Click Here To Register


When States Ordered Nursing Homes to Take COVID-19 PTs, Many Put in Danger
On March 29, as New York and other states began ordering nursing homes to admit medically stable residents infected with the coronavirus, national trade groups warned it could unnecessarily cost more lives.

The health directives put “frail and older adults who reside in nursing homes at risk” and would “result in more people going to the hospital and more deaths,” the American Health Care Association and affiliates said at the time. A month later, it appears government officials should have heeded the dire call to pursue different pandemic emergency plans.

The deadly virus has spread like wildfire through many nursing homes across the Northeast, and state officials are scrambling to better protect those most vulnerable to COVID-19, the disease caused by the virus.

The death toll is devastating, according to interviews with nursing-home officials, patients’ families, health-care advocates, government officials and from an examination of state records by the USA Today Network Atlantic Group, a consortium of 37 Gannett-owned daily newspapers across the Northeast.

  • At least 3,043 people have died inside New York nursing homes due to COVID-19 complications, or about 17% of the state’s 18,015 deaths as of Wednesday.
  • In Pennsylvania, about 65% of coronavirus deaths were nursing-home residents, and New Jersey had 3,200 residents of long-term care homes die due to complications from the virus, about 40% of the statewide total.
  • About 58% of the deaths in Delaware lived in nursing homes, and 46% of the fatalities in Maryland were at nursing homes, prompting Gov. Larry Hogan to order residents and staff members at nursing homes be tested for coronavirus.

Meanwhile, advocates and residents’ relatives have criticized state and federal officials, as well as some nursing homes, for failing to address the crisis as deaths mounted.

“To have a mandate that nursing homes accept COVID-19 patients has put many people in grave danger,” said Richard Mollot, executive director of the Long Term Care Community Coalition in New York. (LoHud, May 1)


Cuomo to Order Insurers to Offer Free Mental Health Services for Essential Workers
Essential workers in New York can soon access free mental health services through their insurance plans, Gov. Andrew Cuomo said today.

The governor said he is directing all insurers to waive any cost sharing, co-pay and deductibles for frontline workers seeking mental health services during the Covid-19 pandemic.

“Too many people, too many families have said to me, ‘Well, I would go for services but I don’t want to pay the cost, I can’t afford it,’” Cuomo said at a morning news conference. “That’s gone. There is no cost to get mental health services. Just wipe that reason away and get the help that you need.”

Cuomo also announced a new emotional support hotline for essential workers. If you need support, call the New York State Emotional Support Hotline at 1-844-863-9314.


NYSDOH Mirrors CDC’s Guidance for Healthcare Facilities’ Employees
On March 16, 2020, the Centers for Disease Control and Prevention (CDC) issued guidance to address employees of healthcare facilities, including nursing homes, suspected of or confirmed to be positive for the COVID-19 virus (Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance)). Under the CDC guidance workers could return to work at a nursing home:

  • “At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
  • At least 7 days have passed since symptoms first appeared.”

The CDC updated their guidance to address asymptomatic workers thereafter.

New York State Department of Health’s guidance mirrored the CDC’s position – however, going forward we will no longer adhere to CDC’s standard on this issue, and will instead require that nursing home employees who test positive for COVID-19 but remained asymptomatic are not eligible to return to work for 14 days from first positive test date in any situation and will no longer adhere to the shorter CDC timeframe. Symptomatic nursing home employees may not return to work until 14 days after the onset of symptoms, provided at least 3 days (72 hours) have passed since resolution of fever without the use of fever-reducing medications and respiratory symptoms are improving. PDF here

Nursing homes must only accept and retain those residents for whom the facility can provide adequate care. 


 

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New York to Hire ‘Army of Tracers’ to Combat Coronavirus
New York will hire up to 17,000 contact tracers as part of a statewide effort to combat the novel coronavirus pandemic by tracking down people who have gone near those infected by Covid-19. New York Gov. Andrew Cuomo said at a Thursday press conference that the state needs at least 30 tracers for every 100,000 people to follow the path of those infected and determine whether their contacts should be isolated. (WSJ 4/30)

Articles:

·       Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic https://jamanetwork.com/journals/jama/fullarticle/2764380