Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large,
Replacing office visits with virtual visits may become the new normal, writes Robert A. Dowling, MD.
In a previous column, “Disaster preparation: Make sure your practice is ready” (December 2018, p. 37), I wrote: “Natural disasters serve as a reminder that most urology practices are small businesses and should have a basic plan in place for dealing with events that cause the temporary or permanent closure of the office. Your plan should address the needs of patients, staff, providers, and the business. Benjamin Franklin said, ‘By failing to prepare, you are preparing to fail.’ While the chances are small you will face a natural disaster, preparation is your best defense.”
Of course, I had no idea that 1 year later we would face a global pandemic that, as I write this article, has disproportionately affected the U.S. and has claimed some 25,000 U.S. lives as of mid-April. No medical practice could have anticipated the scale of this disruption, and it is likely that many small businesses will not survive. It is widely believed an economic recession awaits those businesses that do survive the next few months.
In this article, I will offer a possible vision of what urology practice could look like in the near and intermediate future, and why. I will also share several lessons for urology practices that have come out of the present situation.
Cancelation, postponement of elective procedures
In early March 2020, the U.S. Centers for Disease Control and Prevention, many specialty societies, and many state governors called for canceling or postponing elective procedures, surgeries, and non-urgent outpatient visits. The initial rationale for these recommendations was to preserve valuable resources, but as the virus spread through communities, the broader concern focused on not exposing people to each other and “flattening the curve” of patients requiring those precious resources.
Niche urology practices that have focused primarily or entirely on elective care (vasectomy, erectile dysfunction, uncomplicated BPH) will be significantly impacted. Other practices that have not pursued an intentional strategy may have never understood until recently exactly how much of their practice involved elective, non-urgent care.
While the definition of elective is obvious in some cases, there has been considerable debate as to what other procedures or visits can be postponed without jeopardizing the health of the patient. Prostatectomy for intermediate-risk prostate cancer? A routine visit for active surveillance? A visit for a patient on intermittent androgen deprivation therapy?
We don’t know the answers to these questions because, generally, these types of procedures are scheduled according to personal habits or loose guidelines, not a firm knowledge of the impact of delay. The first major lesson of this crisis is that practices will develop a clearer understanding of what proportion of their business depends on truly elective, semi-urgent, and truly urgent presenting problems, and thus how vulnerable they are to a persistent economic recession. That understanding may guide a strategy for diversification of the business.
Similarly, urology practices tend to think of their business as divided into new patients and established patients. Mature practices may be full of established patients who come in for their “annual visit”; at the other end of the spectrum is the young practice where almost every patient is “new.”
In general, new patients have problems requiring diagnostic evaluation and treatment-bigger sources of revenue for a practice than well-established patients. Some practices are intentional in creating and maintaining a balance of new versus established patients, discharging enough patients in a clinically appropriate way to make room for new patients. The second major lesson of this crisis is that a practice full of annual established patient visits is vulnerable to disruption and that the true value of a practice is to the patient with new and/or acute problems that can only be addressed by a urologist. This understanding may inform a review of your own control over the practice and whether there is an opportunity to restrike the balance of patients.
Urologists may also categorize their skills, and thus their practice, as cognitive and procedural; indeed, this mix of medicine and surgery is often what attracts physicians to the specialty. It is a diversification that may also serve to temper the disruption of the current crisis.
The Centers for Medicare & Medicaid Services (CMS) has issued several waivers and other flexibilities to address the public health emergency. Notable among these changes are those that expand access to telehealth for patients and their providers. Many commercial payers have followed suit, though each with slightly different rules for conducting and billing for the visit. This represents a lifeline for the cognitive side of the urology practice. Many new and established patient visits can now be conducted with the patient and the physician remote from each other using interactive audiovisual technology, in many cases for the same reimbursement as if patient and provider were face to face.
Adoption of this interim solution has been rapid, even as the bugs are still being worked out. The third major lesson of this crisis is that many patients and their problems can be adequately assessed and treated without the need to physically touch the patient. This disruptive innovation is likely to forever change the urology practice, if the flexibilities and reimbursement rules become permanent. The urology office of the future may be primarily designed, built, and operated for the procedural aspects of care, resembling an ambulatory surgery center more than a traditional office. The term “office visit” may be replaced by “tele home visit” as patients come to expect this new normal.
Transitioning staff to ‘remote’ status
Finally, the national efforts to address the public health emergency have resulted in a surge of “remote” workers in the patient care field. It is now apparent that schedulers, call center employees, billing personnel, administrative staff, and even providers do not necessarily need to be in the office to do their jobs in a urology practice. The fourth major lesson of this crisis is that there are opportunities for efficiency and cost savings by transitioning employees to part- or full-time remote offices. The urology office of the future may have less square footage devoted to “the back office.”
Bottom line: One of the tools to deal with uncertainty is to see the possibilities. When the acute public health emergency is over and the future is more certain than it is today, the possibilities include having a practice that does not rely as heavily on elective visits and procedures, cultivates patients that truly need the skills of a urologist, thins out the unnecessary annual visits, and embraces virtual visits using modern technology.