Home Forums Coronavirus and the private practice

Tomorrow I will start taking Plaquenil at 200 mg tid for the foreseeable future. Along with 250 mg of Zithromax, five days on, five days off.

Recent studies have shown rapid cures of Coronavirus on that regimen, extreme decreased transmission, and I will assume chemoprophylaxis. If the combination can cure the disease much faster, then it would make sense that it would be hard for the virus to cause a clinical infection while on it.

Plaquenil by itself is very effective. The combination is significantly better.

I am wondering if I should get an EKG as the combination supposedly increases the QTc. But, it seems everything does.

PS For the past three years, I have gone on 75 mg of Tamiflu daily from December 1 to April 1 along with the flu shot. I have had Influenza A twice and Influenza B once. I was able to work through Influenza B (probably not allowable by the CDC), but both bouts of Influenza A resulted in being out for eight days.

I am seeing the trend of face to face office visits being replaced by secure video chats, got two tomorrow, both patients decided this format rather than risk exposure of leaving their home. Hope if I stay healthy I can keep things running this way for quite a long while.

Have my first 2 telehealth visits scheduled for today also, can almost envision the day where I'm home with my jammies on, one laptop hooked up to doxy.me the other logged into the office AC server.
I remember years ago doing an ER shift talking to a radiologist who just read some xrays on an ER patient and him saying "...no really, I'm sitting on the beach under a palm tree in Hawaii right now!".

Love all the info on this post! We have done only 1 telemedicine visit (video chat). I'm going to talk to the doctor about telephone calls.

Got this email from Cigna today. It seems they covering 99213 via telemedicine ONLY if it's for suspected COVID 19. However, the virtual visit 99241 (the lower paying one) is covered for now. They are only allowing telemedicine 99213 with MDLive.

https://cignaforhcp.cigna.com/publi...Billing-Guidiance-for-Providers-3-18.PDF

Bert, your televisits are over the phone, not video chat right?

Hydroxychloroquine is back ordered and unavailable around here, azithromycin is in short supply.

I would probably do the EKG.

Anyone taking patients off ACE/ARBs?

Thanks

Gene

Hi everyone,

I am probably identifying myself as an old curmudgeon, which may well be the case. But I really have concerns about telemedicine in the family practice setting.

First, I certainly have older patients without smart phones, or who have them and are very limited in their ability to use them.

Secondly, more importantly, I cannot imagine a visit with an older person with multiple problems without a physical exam. What is your blood pressure? Heart regular or irregular? Lungs have rales? Mild ankle edema? Is that back pain just musculoskeletal?

And it would be pretty hard to give a joint injection remotely.

I guess the way to look at it is that telemedicine is better than nothing, which I believe is true. But the idea that televisits will take the place of in office visits long-term seems nonsensical.

Any thoughts?

Thanks.

Gene

For us, it's only going to work for certain visits and they are single problem visits. It's easier for us since we're pediatrics. We're only going to do telemed for asthma checks, minor rash/skin conditions, getting WIC forms signed.

They are over the phone. We don't plan on doing video calls.

Gotcha. I suppose for offices that always run in the black that can be done. We need to see/call patients for everything. There are three types of encounters:

1) in office for those who either want to be seen or need to be seen (sick or need cath or well child)
2) a regular message and triage where the nurse handles it with my input
3) any other appointment, i.e. conjunctivitis, eczema, asthma, acne whatever....if we would have seen them, we either see them or do telemedicine.

On the phone.

Gene,

That wouldn't even be our decision. The insurance companies would never pay once physicians can safely see patients in their offices. As to treating patients that you can't see, this would be the way you would look at it:

a) if your level of care would decrease from a 9/10 to a 7/10, then it is worth it given the pandemic. Everything has to change to some degree.
b) if they are S.O.B. and have edema and your are worried about CHF, then you have to refer them to the ED. But, telemedicine will decrease the EDs being overwhelmed and may even give better care.
c) if we are able to make income during this extremely difficult time, then we can help with patient care, a vital part of the overall strategy

Sure, you will make decisions to do telemedicine where an actual office visit would have been better, but the ICUs will have to triage persons with pHs of 7.1 and O2 sats of 89 to decide who goes on a ventilator.

Do not beat yourself up over whether your care won't be a 9/10 or 10/10 with you.

And, let me say, I don't feel a bit of guilt because in 23 + years, I have likely done over 50,000 messages of which I didn't get paid. Ten thousand pages where I didn't get paid.

By the way, Medicaid will pay their usual reimbursement for telemedicine on all codes. The private insurers may not. MaineCare patients are not going to care about a bill, because their won't be a bill.

How is everyone making sure that private insurance patients or self-pay patients understand that this is a "virtual visit" and their insurance will get billed. They are so used to having a steroid cream called in for poison ivy or eczema in a message that they may not consider this any differently. We are telling them it is an actual visit and that we will be billing their insurance plan for it and documenting it.

We are still not sure about the copay.

Hijacking within threads with similar topics.

I can't remember with all this going on. Is the AAP the organization which is responsible for the four-part testing we go through every five years?

New Criteria

Based on the critical state of testing kit availability, we are only testing Tier One patients according to the chart below based on guidance from the Maine CDC and physician leaders from healthcare systems across the state.

Will be tested:

· Critically ill patients who require hospitalization for their disease
· Healthcare workers and first responders (e.g. EMA, Police, Fire, etc.) performing direct patient care
· People living in a group setting (e.g. long-term care facilities, group homes, assisted living facilities, jails, and shelters)

Will not be tested:

Patients over the age of 60 or those with severe chronic disease/immunosuppression

Will not be tested:

All other patients with symptoms of COVID-19 disease


The Maine CDC will reject tests submitted for asymptomatic individuals and it is important that you fill out the paper work accurately to ensure that Tier One tests are completed. Tests will be prioritized based on the criteria in the table above.

Patients in the Tier Two category should be presumed to be positive and treated with supportive care and follow-up by phone if possible. We will let you know if the availability of tests improves enough that Tier Two patients are eligible for testing.

Patients whose symptoms are consistent with COVID-19, but do not fall into one of these high-risk categories (i.e. patients in Tier Three) should be evaluated and isolated at home. Testing is not recommended for individuals with mild fevers or respiratory symptoms who are not in a high-risk category, confirming infection does not change how mild symptoms are treated and having them present to be tested increases the risk of community spread.

Yes, patients over 60 years of age on chemotherapy should not be tested. It won't change the outcome.

Thank you

PS: We are recommending that every patient throw eggs against the wall of their local police department. Once in jail, they will qualify for testing.

I know this is a moving target, but the recommendations change every day, and each state has different guidelines.

This seems to be the only scenario that the founding fathers forgot to put in the constitution.

I guess a bit different for us because we are doing video chat, but we have created a consent form they must sign. I made the form available on Updox so they can fill in the form electronically w/o having to print out paper. The visit is scheduled like a normal sick visit. At the appointment time, staff calls the patient and collects any copays and verifies the parent name & pharmacy for eRx. Then the patient accesses the doxy.me link and waits for the doctor to accept the video call.

Have successfully done 1 visit so far - it was a private insurance patient and we collected the copay. We have 2 more scheduled this PM and they are medicaid patients.

Strangely, we offered the televisit to 2 asthma checks and they both refused. They still want to come to the office.

We will be starting to do telephone visits too.. still trying to set up all the procedures.

That is very cool. And a good way to get the copay. Plus, given the video, it is more obvious that they see it as a "real visit."

Yes, we are telling all patients they can come in if they wish. If they don't come here, they will go to the ED. We are just super careful about PPE and having them wear masks.

The only downside to your system (at least for me -- maybe not for you) is with the telemedicine we tell them to have their voice mail on and answer the call. But, it allows me to do the call at my convenience, so unlike before I am not running behind an hour and just stressing out all day.

Ended up doing 3 secure video chats (SVC) today, wellness visit on fairly healthy young, one back pain and another anxiety sleep issues, everyone very appreciative to have this option

I asked each one if they saw my portal blast message about this new way to interact and billing for this service (that i sent out to 1000+ patients on wednesday) so all ok with being charged for this service. I told them if any issues with billing to contact our office manager.

Got 4 more scheduled for Monday. Realize SVC has certain limitations, but given the current state of affairs most patients I think will be more than willing to interact this way for simple straight foward issues that are more complex to handle via portal or phone, so learning as I go.

Hi jimmie,

Great news. Sounds really cool. I may have to go to video.

Question though. How are you doing the well visits? Seems like a lot to do via Skype. With extended vitals and more to do on the physical exams.

So, I just saw two kids and a mother. All severe cough and fever. Mild. S.O.B. All within close contact five days ago with a person who tested positive for Covid-19 virus.

Put them on codeine and isolated them at home. I have 65 test kits, but I am not allowed to test them per CDC regulations in Maine. If they were in jail I could.

So, per CDC, it doesn't change their management. But, if they test positive, it is recommended by most health organizations such as WHO to break the chain by going back 14 days from the start of symptoms and find everyone who came in contact with them and test them. So, say it is 8 people. They are tested. Two come back positive. 14 days back for them. Test them.

As it is, people are still allowed to go out for essential services. Maybe one is 19. Maybe she goes to the grocery store, which she would not be allowed to do if she were positive. U.S. is screwed up.

Bert,

I am doing my SVC's at the office at my standing desk, dual monitors, on left I have AC open, on the right Updox, I can see my patient and also myself (to make sure no patient info in background) and I just go thru the usual questions, Past hx, meds, new allergies, social family history updates, vaccines, due for pap, mammo, colonoscopy, all the usual. In terms of vitals, this is evolving, some patients can check BP pulse, most can check weight, but I dictate that this is a secure video chat and a physical and vitals are not being done but in light of the pandemic, patient concerned and self isolating at home. I send in necessary scripts, set up tests if needed (after the "storm" passes), and send summary of visit via the portal after we finish up. If life ever returns to normal I will likely resume annual wellness exams in person when all of this passes but I can foresee that a lot of the simple visits may morph into SVC's in the future.

Very nice. Thanks jimmie.

Do you think we may be able to continue SVCs in the future? Do you think insurance companies would find that not in their best interest?

Bert,

Thank you. I do and I think SVC's will become more common, where maybe a quarter to a third of the visits may be this way, and I don't think insurance companies will care as long as the visits are within the confines of a virtual visit, caring for your own established patients and billing for the service provided. But what the heck do I know, I thought sharing the patient's chart on a 40 inch screen at the point of care I call #ProjectedEHR on twitter, the standard of care by now.

What do you know? Jimmie, you are one of the smartest doctors on this board. You are kind of like my Italy -- if that makes any sense.

Bert, you are too kind, but this board is such a great resource to problem solve in real time and sure appreciate you getting it going again!!! I have never felt this uneasy before, mainly because of how this virus will impact our local medical community in the next few weeks. But I appreciate being able to connect with like minded folks who have helped tremendously over the years with problems that arise from time to time.

HIPAA Waiver:
https://www.hhs.gov/sites/default/files/hipaa-and-covid-19-limited-hipaa-waiver-bulletin-508.pdf

We are doing video chat with Facetime or Whatsapp. Patients love it. How much does UPDOX charge?

177 dollars a month, I am looking at the long range use of the secure video chat after the pandemic passes. I have wanted to do this for such a long time in fact started getting this started in 3/2019, and now is the perfect time to really integrate this into my practice. I still want a HIPAA compliant method as I am concerned once the pandemic passes this requirement will be rei-nstituted, but who knows. In my mind the unlimited efaxing, portal, secure text and now secure video chat management system that Updox provides is well worth it. Makes my job and nurses job much easier, however if Updox decides to lessen their monthly fee I would not be unhappy at all and they may have to to compete with the cheaper players out there.

What is the package that includes all this Jimmie? I still don't see how Facetime and the like are not compliant, as there is no "data in place" being stored. I think Whatsapp is encrypted on both ends; the Chinese citizens love it.

Quote: "WhatsApp's end-to-end encryption ensures that only you and the person you're communicating with can read what's sent. Nobody in between, not even WhatsApp, can read the messages. The messages are secured with locks, and only the recipient has the special key to unlock and read the messages."

I just looked at my recent Updox bill, base fee of 117$ and secure text base fee 60$ per month for a total of 177$ per month (included unlimited efax, patient portal, secure text, secure video chat) We have to sign a BAA with updox each year, so I would assume if these other applications are secure and HIPAA compliant you can sign their BAA (business associate agreement)--I have not researched that so I do not know and maybe you don't have to now, just not sure.

Right now Updox video chat is $20/month with no contract for 6 months.

Our regular updox bill is $70/month, includes portal, non-HIPAA compliant text messaging, unlimited fax and unlimited number of users.

We were having trouble connecting with doxy.me (free) so we signed up for Updox in case there are problems.

We like doxy better because an MA an initiate the video chat and have pt waiting for the dr. to accept the call. Updox is the other way around where the dr has start the call to the patient.

Just to update.. we're doing all sick visits via Telemedicine now. Haven't done any telephone only visits yet. It's an option for patients who cannot do video chat, but so far, everyone has been able to do video chat. But we really do not have that many patients calling in for sick visits so it's very slow here.

Update from Florida. We serve mostly elderly population. Many are delaying routine followup visits. We've offered telemedicine but had few takers. My receptionist is in self quarantine and working remotely.

I did use doxy.me to connect up with a family member during and ACLF visit and it worked great. I upgraded to the pro version ($35/mo) just for the advanced notification options.

My updox bill is now $149 a month!

We still don't have coronavirus test kits.

Just a reminder: in CT, at least, the parity for telehealth/on-site reimbursement on the part of Medicare, Medicaid and private insurance is for 90 days only. No guarantees after that. So don't get too comfortable! :-)
All the same, who knows how long this pandemic will go on, and whether the terms might be extended.

-Kurt
(Office Manager for solo FP doc in Northeast CT)

It's ironic. I think of all the messages patients call about. We hate them. They are more work than seeing the patient. But, they are used to calling in so we can convert them to VV. Virtual Visits.

We get anywhere from 5 to 10 per day. But, I will be using 1800notify.com to send a blast text tomorrow. Over 2000 phone numbers. Of course, some won't be our patients anymore and some will be home numbers, but probably 1500 or so will get through.

The issue is patients either don't want to go out or go to the ED. They DON'T KNOW about telemedicine. We aren't sure when we will get to video. Maybe Facetime, maybe WhatsApp, maybe doxy.me. I guess with older patients, seeing how they appear will be good to do video. There just aren't that many situations where my seeing the patient vs just a phone call will change things. After all, I have done maybe 100,000 pages by phone over the years.

It is to CMS's advantage to have these as it keeps patients from going to the doctors' office or the ED.

I am only doing well visits in the office. We call to confirm and also to check whether they have any respiratory symptoms. If they do, staff will either ask them to call back next week or send me a message to talk to them.
I am doing video chats with doxy.me, which I had set up before but hadn't used much. It occasionally bogs down, but works. It's free.
We are doing background work with deep cleaning and updating a lot of other things in the office. I only am seeing patients 2 days this week!

We mostly do telemedicine only although I think we will offer Facetime just to document that it can be done. I see less patients. Would love to do only two days per week.

The big issue is going to be going back to the old way.

Patient volume (face to face visits plus Telemedicine) down by over 75% in my office. We are having to cut back hours. Maybe need to take out small business loan under the stimulus package to make payroll and pay rent. Details sketchy at this point but looks like SBA will pay fees, principle and interest on loans for 6 months?

I can't even begin to pay any loan even without interest. For the government to even think that would be enough is crazy. So you start back up, which will be slow. And, then you have your usual overhead AND a loan.

So, I am thinking they need to help small businesses, but because we are "front line" you would think we would get some help. Of course, our CDC doesn't consider us front line, you have to be either a fireman or in jail.

I think the problem we face is that most of our patients have no idea we can do telemedicine so we are going to send out blast texts and letters. We have emails on some patients. I wish we had them on all. But, people read their texts.

You sort of have two paths, which one makes you broke and the other makes you rich.

Broke: Do nothing and see 20 patients a week

Rich: Send letters and texts to every patient with a quick explanation of telemedicine and a link to a website with a pdf talking a bit more on about it.

Currently, people are thinking I don't want to go anywhere and I definitely do not want to go to an office full of sick people. There isn't, but that is how they look at it. Like a full waiting room with cough and fever.

But, if they know about the "Virtual visits" and I think they will understand that term, they have no reason to not do it.

Plus, in Maine Medicaid and Medicare have to pay full payments as do the private insurance companies. It is now the law. Even for just telephone visits.

Despite screening patients by a nurse out in the hallway and turning folks away with fever or symptoms, still seeing about 5 face to face in office but seeing 5-10 secure video chats per day and I anticipate the face to face will decrease as the secure video chats increase in next few weeks. The portal message blast telling patients about the screening at the door and option of secure video chats was a double edged sword. I think it slowed down the face to face visits but has helped with getting the secure video chats ratcheted up.

I love the secure visits. I don't think I will want to go back to the face to face. It's like concierge medicine.